Every finding on record at Roubal Care and Rehabilitation Center

All times are in Eastern Daylight Time (EDT) unless otherwise notedBased on interview and record review, the facility failed to ensure five Certified Nurse Aides (CNA) [ F G H I and J] of five CNA's reviewed for competencies had the required yearly competency trainings, including demonstration in skills and techniques necessary to care for residents.Findings include:A review of facility staff personnel records revealed CNA F was hired on 3/13/22. CNA Fs personnel record did not demonstrate yearly competency training.A review of facility staff personnel records revealed CNA G was hired on 11/21/24. CNA Gs personnel records did not demonstrate yearly competency training.A review of facility staff personnel records revealed CNA H was hired on 6/30/23. CNA Hs personnel records did not demonstrate yearly competency training.A review of facility staff personnel records revealed CNA I was hired on 11/6/24. CNA Is personnel records did not demonstrate yearly competency training.A review of facility staff personnel records revealed CNA J was hired on 3/22/24. CNA Js personnel records did not demonstrate yearly competency training.An interview was conducted on 7/28/26 at 12:24 p.m., Business Office Manager (BOM) E reported, I do not have any documentation of competency skill training in the employee files for [CNA F, CNA G CNA H, CNA I or CNA J.].Review of policy titled Competency Evaluation last reviewed/revised 1/1/25, read in part .It is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skills for performing their job.competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristic that an individual need to perform work roles.initial competency is evaluated during the orientation process.subsequent and or annual competency is evaluated.An interview was conducted on 7/28/26 at 1:18 p.m., the Director of Nursing (DON) reported, The competency skills have not been completed with the CNA's.During an interview on 7/29/26 at 11:04 a.m., the Nursing Home Administrator (NHA) and DON acknowledged staff competencies were not completed.

All times are in Eastern Daylight Time (EDT) unless otherwise notedBased on interview and record review the facility failed to ensure a Registered Nurse (RN) was available for eight consecutive hours during a 24-hour period. Findings include:Review of the nursing schedule documents from April 1 through June 30th revealed no RN coverage on the following dates and times:Friday, April 3rd at 6:00 p.m. through Monday, April 6th 6:00 a.m.Friday, April 10th at 4:00 p.m. through Monday, April 13th at 6:00 a.m.Friday, May 1st at 4:00 p.m. through May 4th at 6:00 p.m.Friday, May 6th at 6:00 p.m. through May 11th at 6:00 a.m.Friday, May 15th at 4:00 p.m. through May 18th at 8:00 a.m.Friday, May 29th at 4:00 p.m. through June 1st at 6:00 a.m.Friday, June 12th at 4:00 p.m. through June 15th at 8:00 a.m.Friday, June 19th at 6:00 p.m. through June 22nd at 6:00 a.m.Friday, June 26th at 4:00 p.m. through June 29th at 6:00 a.m.Review of Facility Assessment (FA) last updated 7/1/26, read in part .Facility resources needed to provide competent support and care for our resident population during day-to-day operations and during emergencies.RN.coverage 7 days a week.During an interview on 7/29/26 at 11:04 a.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) acknowledged the concern regarding no RN coverage within the facility during period of April 1st through June 30th.

All times are in Eastern Daylight Time (EDT) unless otherwise notedBased on interview and record review, the facility failed to complete a performance review for five out of five Certified Nurse's Aides (CNA's) at least every 12 months with a potential for inadequate care and unmet resident care needs for all 33 residents residing in the facility.Findings include:Review of facility personnel records demonstrated the following:CNA F was hired on 3/13/22 with no performance review since 2023.CNA G was hired on 11/21/24 with no performance review.CNA H was hired on 6/30/23 with no performance review.CNA I was hired on 11/6/24 with no performance review.CNA J was hired on 3/22/24 with no performance review.An interview was conducted on 7/28/26 at 12:24 p.m., the Business Office Manager (BOM) E reported, I do not have any performance evaluations for CNA F since 2023.I do not have any performance evaluations for [CNA G, CNA H. CNA I, or CNA J] .An interview was conducted on 7/28/26 at 12:47 p.m., the Director of Nursing (DON) reported, The performance evaluations for the staff have not been completed.Review of the Facility Assessment (FA) last updated 7/1/26, read in part .The individual's job description outlines the basic job skills that are requires, and staff are evaluation annually on their performance.During an interview on 7/29/26 at 11:04 a.m., the Nursing Home Administrator (NHA) and DON acknowledged performance reviews were not completed.

Based on observation, interview and record review, the facility failed to have an active and ongoing plan to reduce the risk of legionella and other opportunistic pathogens of premise plumbing, resulting in the potential for increased risk of respiratory infection among all residents. Findings include:On 7/27/2026 at 2:10 PM in the Groom Room beauty salon, the hair wash sink faucet was observed leaking and had rusty slime, hair, and grime around the faucet and into the sink.On 7/28/2026 at 9:06 AM, the lift tub had dust and debris around the drain. Maintenance Director (MD) R stated the tub had not been used for a couple of years and was not on the flushing schedule. The water ran brown for several seconds when the faucet was turned on.On 7/28/2026 at 9:33 AM in the 400 wing bath, the tub used to wash wheelchairs was soiled with dust and debris. MD R confirmed the tub was not on any flushing schedule. The old shower faucet was leaking and had mineral and slime buildup.On 7/28/2026 at 11:54 AM record review of the water management plan, the above areas were not included in the flushing schedule.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of resident equipment and the interior of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents in the facility.Findings Include:On 7/27/2026 at 11:51 AM the windowpane in the resident lounge, which is also used for equipment and sling storage, was observed broken, with condensation built up between the glass. On 7/27/2026 at 12:25 PM, seven overhead light fixtures in the kitchen had non working bulbs, leaving the area dim for food preparation. Maintenance Director (MD) R stated he agreed the kitchen was dark and had noticed the bulbs were out the previous week.On 7/27/2026 at 12:50 PM windowpanes were observed broken on 400 Hall south. One pane was noted broken in the lounge, and one pane was observed broken in the room labeled 'Recliners & Chairs/Tables'. On 7/27/2026 at 2:07 PM a fall mat was observed lying on the floor of room [ROOM NUMBER], where the resident was out of the room. The fall mat was cracked and no longer smooth, durable or easily cleaned. On 7/28/2026 at 7:28 AM Central time (8:28 AM Eastern) the dining room was observed having four of the eight overhead lights out and the dining room seems dark and not well lit. (MD) R was asked why the dining room was so dark, and they stated that they had seen the bulbs were burnt out and they already had the bulbs to replace them, and they just had not had time to do so. On 7/28/2026 at 9:04 AM while in the 100-wing Bath the caulking around the base of the shower was noted soiled, stained and in disrepair. MD R stated this was in need of replacing, and that the tiles underneath also looked as if they needed to be replaced. On 7/28/2026 at 9:33 AM peeling paint was observed on the walls in the 400-wing bath which is used for wheelchair washing.

All times are in Eastern Daylight Time (EDT) unless otherwise notedBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect residents' use of bed and chair alarms for 3 Residents (#1, #3, & #14) of 12 residents reviewed for MDS accuracy.Findings include: Resident #1 (R1) On 7/27/26 at 1:27 PM and 7/28/26 at 8:12 AM, R1 was observed in the dining room with an alarm attached to the back of his specialized wheelchair. On 7/27/26 at 3:01 PM, an alarm was observed attached to R1's bed. Review of R1's fall care plan revealed an intervention initiated 6/19/25 that read: I use alarms when in bed/chair. Ensure alarm is in place and operational. A review of R1's MDS assessments revealed inaccurate coding in Section P0200A (Bed Alarm) and P0200B (Chair Alarm). Despite documented and observed use of bed and chair alarms, the assessments dated 7/28/25, 12/17/25, 2/2/26, 2/9/26, and 5/11/26 were coded alarms as not used. These assessments were completed after implementation of the care plan intervention directing the use of alarms. Resident #3 (R3) On 7/27/26 at 3:28 PM, R3 was observed attending an activity in the pavilion with a wheelchair alarm attached to the back of her wheelchair. On 7/28/2026 at 9:50 AM, R3 was observed lying in bed in her room. An alarm was noted to be attached to her bed. The fall care plan of R3 included an intervention initiated 2/24/26 that read: I use chair/bed alarm per POA request. Ensure alarm is in place and operational. Place my alarms out of sight as I often fiddle with it/turn off. Review of MDS assessments completed after implementation of the alarm intervention revealed inaccurate coding in Section P0200. The assessments dated 3/30/26, 4/27/26, and 7/27/26 identified R3 as not using bed or chair alarms despite documented care plan interventions and direct observation confirming their use. On 7/29/26 at 11:29 AM, during an interview, Registered Nurse (RN) K confirmed she was the MDS nurse and was responsible for coding section P of MDS assessments. RN K confirmed the use of bed and chair alarms is coded in Section P and stated she utilized residents' care plans when completing this section. She further confirmed residents with care plan interventions directing the use of alarms should have those devices accurately coded on the MDS in Section P. After being informed several residents had documented and observed bed and chair alarms that were omitted from Section P coding, RN K stated, I must have missed it. Resident #14 (R14) On 7/29/26 at 11:38, R14 was observed lying in her bed with a bed mat alarm and an alarm attached to her wheelchair The fall care plan included an intervention last revised 2/13/26, that read .I use chair/bed alarms. Ensure alarm is in place and operational. Review of R14's MDS assessments completed after implementation of the alarm intervention revealed inaccurate coding in Section P0200A (bed alarm) and P0200B (chair alarm). Despite care planning documentation and observed use of bed and chair alarms, the assessments dated 3/17/26 and 6/17/26 were coded for alarms as not used. These assessments were completed after implementation of the care plan intervention directing the use of alarms. The policy Conducting an Accurate Resident assessment dated as reviewed/revised by RN K on 6/1/25 read, in part: .all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment .

All times are in Eastern Daylight Time (EDT) unless otherwise noted.Based on interview and record review, the facility failed to provide applicable bed hold policy information and/or written transfer notifications to two Residents (#37 & #38) of four residents reviewed for transfer and discharge process.Findings include:Resident #37 (R37)The medical record for R37 revealed a census record on 7/9/26 indicating R37 was sent out to the hospital. The medical record did not contain a written notification of discharge or written notification of the bed hold policy/rights sent to the resident or the responsible party.Resident #38 (R38)The medical record for R38 revealed a census record on 7/1/26 indicating R38 was sent out to the hospital. The medical record did not contain a written notification of discharge or written notification of the bed hold policy/rights sent to the resident or the responsible party.On 7/29/26 at 10:15 AM, a request was made to the Director of Nursing (DON) for documentation of any written notification of hospital transfer and bed hold policy notifications for R37 and R38 for their hospitalizations in July 2026. At 10:25 AM that same day, Social Services Director (SSD) L indicated they were unable to locate any documentation regarding written notification of a bed hold for the two transfers. SSD L stated, I am sorry. I must have missed them.Both R37 and R38 were unavailable for an interview during the survey process.Review of policy titled, Bed Hold, dated 7/14/25, read in part Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed.

All times are in Eastern Daylight Time (EDT) unless otherwise notedBased on observation, interview, and record review, the facility failed to ensure a urinary catheter drainage bag was maintained off the floor and secured in a privacy bag for one Resident (#1) of one resident reviewed for catheters.Findings include:Resident #1 (R1) was admitted to the facility 1/26/24. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine indicating R1 had moderately impaired cognition. The MDS documented R1 had a urinary catheter and was dependent on staff for most activities of daily living (ADL). The care plans for R1 included an intervention dated 2/12/24 that read: Cover collection/drainage bag with privacy bag at all times.On 7/27/26 at 1:27 PM and 7/28/26 at 8:12 AM, Resident #1 (R1) was observed seated in the dining room in a specialized wheelchair with a urinary catheter drainage bag resting directly on the floor. The drainage bag was not enclosed in a privacy bag (a bag that conceals a urine collection bag from view to promote privacy and maintain dignity).R1 was observed in the hallway near the nurses' station with other residents present on 7/27/26 at 2:10 PM. The urinary catheter drainage bag was resting directly on the floor beneath the wheelchair and was not secured in a privacy bag.At 10:53 AM on 7/28/26, R1 was observed lying in bed with the urinary catheter drainage bag resting directly on the floor beside the bed. The drainage bag was not enclosed in a privacy bag.During an observation conducted at 7:58 AM on 7/29/26, R1 was observed seated in his wheelchair in his room. The urinary catheter drainage bag was on the floor beneath the wheelchair without a privacy bag.On 7/29/26 at 8:10 AM, Certified Nurse Aide (CNA) D was observed transporting R1 by wheelchair into the dining room. During transport, the urinary catheter drainage bag was dragging across the floor beneath the wheelchair.On 7/29/26 at 8:11 AM, CNA A was asked about the drainage bag of R1. CNA A said the drainage bag should be in a privacy bag and should not be touching the floor. CNA A removed R1 from the dining room. When R1 was brought back into the dining room on 7/29/26 at 8:27 AM, the urinary drainage bag had been placed in a privacy bag and secured under the wheelchair of R1. The drainage bag was no longer touching the floor.During an interview with the Infection Preventionist (IP) on 7/29/26 at 9:30 AM, the IP said R1 had a history of urinary tract infections. The IP confirmed urinary drainage bags should never touch the floor. The IP said the drainage bag was expected to be maintained in a privacy bag.The policy Catheter Care dated as reviewed/revised 3/30/24 read, in part: .It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Privacy bags will be available and catheter drainage bags will be covered at all times while in use.

All times are in Eastern Daylight Time (EDT) unless otherwise noted. This citation pertains to intake #3072295 & #3072396 Based on interview and record review, the facility failed to assess, monitor, and document a change in condition per standards of practice for one Resident (#38) of twelve residents reviewed for quality of care.Findings include:Resident #38 (R38)The medical record for R38 revealed an original admission to the facility on 4/1/23 and was sent out to the hospital on 7/1/26. R38 had diagnoses including diabetes mellitus, cerebral infarct (stroke), and weakness.Review of intake # 3072295 reported to the State Agency (SA), dated 7/1/26, read in part Patient in nursing home was not checked throughout the day and was reported in the afternoon to be having stroke-like symptoms. Patient's last check was previous day. Patient normally verbal and able to move self-using a wheelchair was found to be non-verbal, little to no motor function, and significant facial droop.Review of intake # 3072396 reported to the SA, dated 7/6/26, read in part .on 6/30, the facility noticed drooping on [R38's] face.did not call [family] until 7/1, and they told.she had been unresponsive all day.they did not provide a time.or exactly when they noticed that her face was drooping.[R38] was sent to [out of state hospital] [R38] was diagnosed with a stroke.the doctor told her that they could send her to [another hospital] for more assistance, but it was too late because they did not know how long she had been in that condition.Review of R38's progress notes, dated 6/30/26 and 7/1/26, revealed the following:6/30/26 at 9:50 PM (Central Time Zone (CTZ)), read Res [resident] had just received a shower on this date and a full assessment along with vital signs were taken in which all were WNL [within normal limits]. It was noted that res was closing her eye left eye a little tighter than right eye. Res does have chronic droopy eye which is per her normal. She did not have any complaints prior to going to bed. Res was more quite (sic) than usual, so writer checked on res a few times in the night. In which all vitals remained WNL. No further issues noted. *Late entry note added on 7/10/26 at 7:12 AM (CTZ),7/1/26 at 8:30 AM (CTZ), read Resident was noted to be sleeping in her bed this am, which isn't out of the ordinary for her as resident often refuses meals and likes to sleep. CNA provided cares but resident didn't wake up to eat breakfast. Will continue to monitor. *Late entry note added on 7/9/26 at 1:23 PM (CTZ),7/1/26 at 10:24 AM (CTZ), read Writer performed pain assessment. Resident asleep in her bed with no discomfort or distress noted. *Late entry added on 7/9/26 at 1:35 PM (CTZ), and7/1/26 at 2:25 PM (CTZ), read Resident has a right facial droop. She is moving her left arm but will not open her eyes or respond. VSS. Daughter notified and will come in to see her and evaluate whether she wants her seen in the ER. Resident has been sleeping all day.7/1/26 at 2:55 PM (CTZ), physician called and 911 called. At 3:15 PM (CTZ), R38 left in ambulance to emergency room.Review of R38's electronic medical record (EMR), dated 6/30/26 & 7/1/26, lacked vital signs on 6/30/26 and lacked a head to toe and neurological assessment for R38 related to having a change in condition on 7/1/26.On 7/28/26 at 7:39 PM, during a phone interview, Emergency Medical Technician (EMT) P was asked about the transfer on 7/1/26 with R38 and replied, We got a call for signs and symptoms of a stroke for [R38] and went to assist. [R38] unresponsive. Had to wait for doctor approval for transfer. [R38] had facial drooping and no movement. Asked the staff of last known well and replied to last night. There was like a 16-to-12-hour window where no one could say when she was last known well and no one checked on her. [R38's] mouth was wide open when we arrived on site.On 7/28/26 at 8:18 PM, during a phone interview, Family Member Q was asked about the transfer out on 7/1/26 with R38 and replied, The facility told me my mother [R38] had been unresponsive all day and wanted to know what I wanted to do. I got to the facility, and her mouth was wide open, and she was looking off into a distance. Rescue squad arrived and [R38] face was drooping since the day before, identified by nurse [Licensed Practical Nurse (LPN) N] and stated she was just going by what she knew. At the hospital it was noted that [R38] had two blood clots in her carotid arteries. If they had known sooner, they could have prevented, but the facility waited 18 to 20 hours before calling me and sending her out.During an interview on 7/28/26 at 8:36 PM, Certified Nursing Aide (CNA) J was asked about R38 being transferred out on 7/1/26 and replied, I was the CNA that day and I went into her room [R38's] between 6:15 AM and 6:30 AM and she looked like she was sleeping. I got her dressed by myself and she didn't really seem like herself. I got the [Assistant Director of Nursing (ADON) C] and told her something was wrong. Lunch came I did not feed her and tried to wake her up and she would not wake up so I got the nurse [LPN N] around 2:00 PM. [R38] will not normally eat breakfast, but she always eats lunch. The day before she was fine [6/30/26]. The following day she was not fine [7/1/26].On 7/29/26 at 9:10 AM, an interview was conducted with LPN N regarding the transfer of R38 and replied, I forgot to make a progress note so I added it when I worked next. I went to check on her the day she was transferred out. LPN N was asked what kind of assessment she competed on R38 before calling family and replied, I took her vital signs. LPN N was asked if she did a neurological assessment and replied, No. She [R38] had a history of having a prior stroke and that's what it looked like to me. Only moving one arm and I could not wake her up like she normally arouses. Her level of activity was not normal. I could not pinpoint what was wrong. The CNA came to get me around 2:00 PM and said she felt she was not right.On 7/29/26 at 9:30 AM, an interview was conducted with LPN / Assistant Director of Nursing (ADON) C who was asked what her expectations were about charting and replied, If a change in condition nurses need to be documenting at the time of the change in condition, vital signs, and charting an assessment. ADON C was asked why the charting was added as a late entry nine and ten days after R38's change in condition and replied, I don't know why it would be that late. If it was not charted it was not done.On 7/29/26 at 11:45 AM, an interview was conducted with the Director of Nursing (DON) who was asked about her expectations for nurses charting and replied, If it was not documented it was not done. The nurse should have charted an assessment including neuros and I do not see that it was done. I just saw vital signs were in normal limit. No situation background assessment or report [SBAR] or a change in condition evaluation.On 7/29/26 at 12:00 PM, an interview was held with LPN N regarding the late entry progress note on 7/1/26 which was created on 7/9/26. LPN N was asked why she did not make the note sooner when she worked on 7/2, 7/7, and 7/8 and replied, I don't know. Yes, I was asked to add in a progress note by the DON.Review of policy titled, Notification of Changes, dated 1/23/26, read in part Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Definitions: 'Life-Threatening Conditions'; Examples - Heart Attack or Stroke.Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and / or notify the resident's family member or legal representative when there is a change requiring such notification.

Based on interview and record review, the facility failed to ensure adequate supervision and proper use of assistive devices (gait belt and wheelchair) to prevent a fall with major injury (fractured femur) for one Resident #37 (R37) out of one resident reviewed for falls. This deficient practice resulted in harm when R37 fell while ambulating with staff and subsequently fractured his femur requiring a surgical hip repair. Findings include:All times noted are in Eastern Daylight-Saving Time (EDST), unless otherwise noted. Resident #37 (R37) Review of R37's Progress Notes revealed the following, in part: 1/12/2025 15:44 ([:44 Central Standard Time (CST)]: Resident ambulating in hall with staff assistance, utilizing walker, wheelchair to follow. Stopped to sit in WC (wheelchair) lost balance and fell from standing position into wall on right side of body head hitting cement wall .Resident complains of right hip pain, unable to lift right leg. Appears misaligned .1/12/25 16:01 (4:01 p.m. CST); Resident left with paramedics at this time .1/12/25 18:35 (6:35 p.m. CST); .resident is being admitted with hip fracture . POC (plan of care) was being followed as in gait belt on, resident pushing walker and staff had WC follow .1/13/25 11:18 CST: Imaging showed an acute intertrochanteric and subtrochanteric fracture of the right femur. Plan: To OR (operating room) tomorrow for . nailing of right hip fracture.1/13/25 21:11 (9:11 p.m. CST); Team (IDT) discussed this fall - education will be provided to CNAs.Review of R37's Incident Report, dated 1/12/2025 at 15:36 (3:36 p.m. CST) revealed the following, in part: Nursing Description: Resident ambulating in hall with staff assistance with gait belt on, utilizing walker with wheelchair to follow. Stopped as wanted to sit in WC feeling weak, lot balance and fell sideways from standing position into wall on right side of body, also hitting head on cement wall. Resident Taken to Hospital? Y (yes), No injuries observed at time of incident . Injuries Report Post Incident: No Injuries Observed Post Incident . Level of Pain: Blank . Statements: Staff (Certified Nurse Aide (CNA) P: [R37] had been wanting to go for a walk, so I went to take him for a walk. I put his gait belt on and gripper socks on and then we went for the walk. As he pushed his walker down the hall, I had one hand on his gait belt and had WC follow with the other hand. He was walking along nice and strong then all of a sudden he said he needed to sit and as I went to hold his arm and push WC up, he just collapsed over.Review of a Therapy Recommendations - PT (Physical Therapy) document provided by the facility on 6/26/25 at 11:40 a.m., revealed the following PT recommendations as of 1/3/2025: Resident [R37], Recommendations: Please amb (ambulate) pt (patient) with FWW (front wheeled walker) with CGA [(contact guard assist requires a hand on the client (such as with a gait belt)] and W/C (wheel chair) follow 60 ft or as tolerates X1-2 a day, room to desk.Review of a Therapy Recommendation - OT (Occupational Therapy) document provided by the facility on 6/26/25 at 3:43 p.m., revealed the following OT recommendation: [R37] Recommendations: Contact guard - Min. (minimum Assist X 1 for functional transfers. During an interview on 6/26/25 at 3:42 p.m., CNA P who was walking R37 at the time of his fall on 1/12/25, reported R37 was walking well and then said that he wanted to sit down, he was getting tired and wanted to sit down. I initially had my right hand on the back of his gait belt, and my left hand reaching behind and pulling along his wheelchair. I went to grab his arm and turned to pull the w/c up so that he could sit in it and he went down. When asked what hand she used to grab his arm, she initially said her right hand - that had been on his gait belt and then used her left hand to pull the wheelchair behind him. Then she stated that she doesn't really recall because it was quite a while ago. When asked if she had been re-educated, CNA P said that they told her that she did everything right, but the next time she should keep her hand on the gait belt, stay facing the resident's back, and get someone else to help pull the wheelchair. When asked if she was aware that R37 was a CGA contact guard assist, CNA P said she was not aware of that, but thought he was an assist of one during ambulation.

Based on observation, interview, and record review, the facility failed to maintain best practices in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.Findings include: During a tour of the walk-in cooler, at 7:58 AM on 6/25/25, it was observed that storage racks in the walk-in cooler were found with an accumulation of debris on the open wire rack shelving. Observation of the floor in the walk-in cooler found a dried yellow spill on the floor as well as an accumulation of debris and paper trash under racks and alongside the perimeter of the floor. During a tour of the walk-in freezer, at 8:00 AM on 6/25/25, it was observed that the floor of the walk-in cooler was full of paper trash debris from date marking stickers. During a tour of the clean utensil drawer, at 8:38 AM on 6/25/25, it was observed that an accumulation of crumbs were found along the back wall of the drawer. When asked how often this area gets cleaned out, Dietary Manager (DM) I was unsure. During an interview with DM I, at 8:40 AM on 6/25/25, it was found that the stand-up mixer gets used a few times a week for mashed potatoes. When asked what the plastic bag covering the mixer meant, DM I stated it was to keep the mixer clean. Observation of the mixer found white dried food debris smeared on the under arm of the unit. During a tour of the cook line, at 8:48 AM on 6/25/25, observation of the manual can opener at the end of the cook line found increased accumulation of rust and pitting on the can opener bar and inside mechanism for turning the can opener. When asked if the can opener gets used much, DM I stated that staff typical use the electric can opener. Observation of the electric can opener found a dark black accumulation of debris behind the blade. When asked if the electric can opener had been used today, DM I asked staff and stated it was not. During a tour of the pantry, at 9:06 AM 6/25/25, it was observed that increased accumulation of food debris was evident on the inside top of the unit. When asked about the microwave, DM I stated she will have to add it to the cleaning list for her staff. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean .During an interview with DM I, at 8:11 AM on 6/25/25, it was found that staff get their sanitizer from the janitors sink daily and fill up spray bottles to use with rags. Observation of the facility provided test trips found expiration dates of March 15th, 2020, and October 5th, 2021. Further review found a sanitizer spray bottle located on a table near the back dish machine area entrance. At this time, the spray bottle was tested and found to be 0 to 50 parts per million (ppm). A sanitizer bucket was poured from the janitors sink, by DM I and found to be well over 500 ppm. When asked about the inconsistency in sanitizer level, DM I was unsure and stated would get ahold of the vendor. According to the 2022 FDA Food Code section 4-302.14 Sanitizing Solutions, Testing Devices. A test kit or other device that accurately measures the concentration in MG/L of SANITIZING solutions shall be provided.According to the 2022 FDA Food Code section 7-204.11 Sanitizers, Criteria. Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A) Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions)P, or (B) Meet the requirements as specified in 40 CFR 180.2020 Pesticide Chemicals Not Requiring a Tolerance or Exemption from Tolerance-Non-food determinations.During a tour of the facility kitchen, at 8:43 AM on 6/25/25, while in the clean pots and pans storage area, two full pans and two half pans were noted having been stored wet, without proper air drying having occurred prior to stacking. Upon interview with DM I, it was agreed that the pots and pans are to be properly air dried after wash, rinse and sanitizing and prior to storage.According to the 2022 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD .

Based on observation, interview, and record review, the facility failed to:Ensure the use of infection control measures were practiced according to current guidelines and professional standards of practice for three Residents (#31 and #13) of 11 residents reviewed for infection control practices.Have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Resident #31 (R31)Review of the Minimum Data Set (MDS) assessment, dated 5/22/2025, revealed R31 was admitted to facility on 8/14/2024 and had diagnoses including obstructive uropathy, peripheral vascular disease, morbid obesity, and depression. Further review of the MDS assessment revealed R31 had an indwelling urinary catheter, was always incontinent of bowel, required substantial/maximal staff assistance for toileting hygiene and bathing, and was dependent on staff for all transfers and mobility. R31 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he was cognitively intact. On 6/25/25 at 8:59 a.m., an observation in the 300 Hall revealed the door to R31's room was closed. A Centers for Disease Control and Prevention (CDC) sign was observed on the outside of the door indicating the use of Enhanced Barrier Precautions (the use of gowns and gloves during high-contact resident care to reduce the spread of multidrug-resistant organisms [MDROs]) in the care of R31. Further review of the sign revealed the following:Enhanced Barrier Precautions. Everyone Must . Wear gloves and gown for the following High-Contact Resident Care Activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing Briefs or assisting with toileting. Device care or use: central line, urinary catheter . Wound care .On 6/25/2025 at 10:55 a.m., R31's morning care was observed as provided by Certified Nursing Assistant (CNA) K and CNA N. CNA N was observed preparing to empty R31's urinary catheter drainage bag into a clear, graduated cylinder while CNA K donned a protective gown and gloves. Further observation revealed CNA N with gloved hands and no protective gown filling the cylinder with urine from the bag. CNA N then walked toward the bathroom with the cylinder of urine at which time she noticed CNA K wearing a protective gown. CNA N stated, Oops, that's my first mistake, then proceeded to empty the urine in the toilet and returned to empty the remaining urine from the bag into the cylinder then into the toilet, without donning a protective gown. On 6/25/2025 at 3:33 p.m., CNA K and CNA M were observed preparing R31 for a transfer from his bed to his recliner. Initial observation revealed R31 lying in bed wearing a disposable incontinence brief and his shorts pulled down to his mid-thighs, no other covering was present. R31's urinary catheter drainage bag was attached to the right side of the bed frame with dark, yellow urine was observed to be present in the tubing. R31 was rolled to the left then right as the CNAs, wearing gloves and no protective gowns, pulled R31's shorts over his hips and buttocks then positioned the lift sling underneath the Resident. CNA K was observed to position the catheter drainage bag on the lift in preparation for the transfer. R31 was then transferred to the reclining chair with CNA M supporting R31 while CNA K operated the lift. It was noted neither CNA K or CNA M wore protective gowns during the care or transfer of R31. During an interview immediately after the observation, the CNAs were queried regarding the use of EBP in the care of R31. CNA M reported they did not provide catheter care, therefore EBP was not indicated. When asked to clarify in what instances EBP was warranted for use in the care of R31, CNA M stated, only direct care of the catheter. When asked how they knew what cares call for the use of EBP, both CNA M and CNA K reported they referred to the care plan and the signage of the Resident's door.Review of R31's comprehensive care plan revealed no intervention listed related to the use of EBP in the care of R31.On 6/26/2025 at 1:30 p.m., the Assistant Director of Nursing (ADON)/Infection Preventionist reported EBP was to be utilized in all high contact care of residents with indwelling medical devices, such as indwelling urinary catheters and residents with open wounds. The ADON was queried as to what constituted high contact care activities and confirmed transfers and catheter care warranted the use of EBP.Review of the facility policy titled, Infection Prevention and Control Program, last revised 6/05/2024, revealed procedures for the use of Standard Precautions and Transmission-Based Precautions (TBP). Further review revealed no procedure listed for the use of EBP.Review of the CDC guidance titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant organisms (MDROs), dated 4/02/2025, revealed the following:Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce the transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities . more than 50% of nursing home residents may be colonized with an MDRO, nursing homes have been the setting for MDRO outbreaks, and when these MDROs result in resident infections, limited treatment options are available . Resident #13 (R13)Review of R13's MDS assessment, dated 5/14/25, revealed admission to facility on 4/1/23 with diagnoses that included: End-Stage Renal Disease (ESRD) and dementia. Further review of the MDS assessment revealed R13 had one unstageable, suspected deep tissue injury that was not present upon admission. R13 did not complete the BIMS but was documented with severely impaired cognition.On 6/25/25 at 10:01 a.m., RN A was observed as she prepared the room and R13 for wound care. Neither RN A or IP/RN H (also present during the observation) donned gowns for enhanced barrier precautions prior to performing/assisting with wound care for R13. RN A performed hand hygiene and donned clean gloves prior to pulling the Resident's privacy curtain closed with her gloved hands. RN A with the same gloves placed an absorbent barrier pad underneath R13's right ankle. RN A removed the old, soiled dressing, dated 6/24/25, on R13's right lateral ankle bone. RN A opened a package of sterile gauze 4x4's with her contaminated gloves, touching the interior and exterior of the sterile gauze pads. Normal saline was applied to the now contaminated gauze pads, and the wound was cleansed using the same dirty gloves. Another sterile 4x4 gauze pad was saturated with normal saline, and the wound was cleansed again. RN A took the tube of Medi honey, placed ointment on a sterile tongue depressor and applied it to the wound bed. RN A removed her gloves and washed her hands in the Resident's bathroom. She then placed her clean left hand into her scrub top left pocket and donned the gloves retrieved from her scrub top pocket. The dressing was dated 6/25/25, and the Mepilex dressing was applied to R13's wound with potentially contaminated gloved hands. During an interview on 6/26/25 at 9:30 a.m., RN A was asked when hand hygiene should be performed after touching environmental surfaces during wound care. RN A stated, After I touched all those things (privacy curtain, dirty bed linens, and other environmental surfaces). RN A said she knew that after she did the wound care yesterday, but she was already done with the care so there was nothing she could do about it then. When asked if the inside of her scrub top pocket was clean or dirty, RN A said Dirty. RN A acknowledged she should not have reached into her scrub top for the gloves with clean hands. RN A confirmed the observation did not demonstrate appropriate infection control practices during wound care. On 6/25/25 at 10:00 a.m., observation on the 200 Hall revealed the door to R13's room was closed. A Centers for Disease Control and Prevention (CDC) sign was observed on the outside of the door indicating the use of Enhanced Barrier Precautions (the use of gowns and gloves during high-contact resident care to reduce the spread of multidrug-resistant organisms [MDROs]) in the care of R13. Further review of the sign revealed the following: Enhanced Barrier Precautions. Everyone Must . Wear gloves and gown for the following High-Contact Resident Care Activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing Briefs or assisting with toileting. Device care or use: central line, urinary catheter . Wound care . During a follow up tour of the kitchen, starting at 7:50 AM on 6/25/25, it was observed that water lines were protruding from behind the cook line and found not attached to any pieces of equipment. Further observation found a mop sink faucet under and off to the right of the three-compartment sink. An interview with Dietary Manager I found that staff never use the faucet and were unaware that it was there. The faucet was found still hooked up to the facilities domestic water as water would dispense onto the floor when turned on. These fixtures indicated stagnant water lines in the facility. During a tour of the 100-hall soiled utility room, at 11:31 AM on 6/25/25, observation of the cold water, coming from the mop sink faucet over the hopper, found discolored water dispensed out of the faucet and that gave a yellow tinge to the water in the basin. When asked if staff use the hoppers, Housekeeping Lead (HL) J, stated that staff do use the hoppers, but typically just the hot water. During a tour of the 100-hall bath, at 11:37 AM on 6/25/25, an interview with HL J found that staff don't use the tub in this room. Observation of the tub found an accumulation of dust and debris, indicating minimal use and a possible stagnant water line. During a tour of the 200-hall soiled utility, at 11:54 AM on 6/25/25, it was observed that the water line for the spray hose on the hopper was turned off at the source. Using a plumbing key, the spray was turned on and found to dispense discolored yellow tinged water into the basin of the hopper. During an interview with the Director of Nursing, at 1:40 PM on 6/25/25, it was found that she has not been part of the Water Management Team and questions should be directed to Environmental Services Director (ESD) G. During a record review of the facility provided document, entitled Water Management Program, reviewed / revised on 1/7/25, found under the heading Policy Explanation and Compliance Guidelines the first requirement states that .A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing. During a tour of the 400 hall, with HL J, starting at 1:52 PM on 6/25/25, it was found that the beds in the hall have been decertified, and this area has not been used for residents since before HL J started a couple years ago. When asked if housekeeping has any responsibility in this hall. HL J stated that she makes sure that water is in the basins of the sinks and toilets so that sewer gas doesn't escape and create odors. When asked if any of the water fixtures get flushed regularly, HL J stated that she didn't believe the water was on in these rooms and that's why she must carry a bucket down to fill them. Observation of the shared bathroom for rooms [ROOM NUMBERS], at 1:55 PM on 6/25/25, found that the commode water was low in the bowl and was able to be flushed, indicating the water was active on this hall with numerous stagnant lines not being regularly flushed. An interview with ESD G, at 2:34 PM on 6/25/25, found that the facility does not take any water samples, such as for disinfection, as a part of their water management plan. When asked about flushing water in the facility to remove stagnation from minimum use or unused water fixtures, ESD G stated once a month we check the commodes to make sure they have water in them, but there is not a routine flushing schedule for water fixtures. When asked if the facility has any control measures to reduce the risk of Legionella or OPPP, such as implementing a kill step in their hot water system at 140 F, ESD G was unsure and stated the hot water system for domestic use is set at 117 F. During a further record review of the facility provided document, entitled Water Management Program, reviewed / revised on 1/7/25, found Control measures will be applied to address potential hazards at each control point. A variety of measures may be used, including physical controls, temperature management, disinfectant level control, visual controls, or environmental testing for pathogens. The measures shall be specified in the water management program action plan .When control limits are not maintained, corrective action will be taken and documented accordingly.

Based on observation, interview, and record review, the facility failed to maintain sanitary oxygen tubing for three Residents (R6, R32 and R34) of four Residents reviewed for respiratory care.Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted.Resident #6 (R6)A review of R6's electronic medical record (EMR) revealed an initial admission to the facility on 4/24/25 with diagnoses including chronic diastolic congestive heart failure. A review of R6's Minimum Data Set (MDS) assessment, dated 5/5/25, revealed Section O (Special Treatments and Programs) reported while residing in the facility R6 required the use of oxygen. A Physician's order was written for R6 Change oxygen tubing weekly, date and initial tubing with each change.On 6/26/25 at 3:24 PM, R6 was observed in her room with an oxygen concentrator. The oxygen tubing was dated as last changed on 6/16/25.Resident #32 (R32)A review of R32's EMR revealed initial admission to the facility on 2/7/25 with diagnoses including chronic systolic congestive heart failure. A review of R32's MDS assessment, dated 5/22/25, revealed Section O (Special Treatments and Programs) reported while residing in the facility R32 required the use of oxygen. A Physician's order was written Change oxygen tubing, date and initial tubing Start Date 4/20/2025.On 6/24/25 at 12:59 PM, R32 was observed receiving oxygen via tubing from a concentrator. The tubing was dated as last changed on 6/16/25.On 6/26/25 at 11:47 AM, R32's room was observed with an oxygen concentrator. The oxygen tubing was dated as last changed on 6/16/25.Resident #34 (R34)A review of R34's EMR revealed initial admission to the facility on 4/11/2025 with diagnoses including chronic systolic congestive heart failure. A review of R34's assessment, dated 4/17/25, revealed Section O (Special Treatments and Programs) reported while residing in the facility R34 required the use of oxygen. The EMR included a Physician's order written for R34, Change oxygen tubing weekly, date and initial tubing with each change.On 6/26/25 at 3:31 PM, R34's room was observed with an oxygen concentrator. The oxygen tubing was dated as last changed on 6/16/25.During an interview on 6/26/25 at 11:50 AM, the Director of Nursing (DON) stated oxygen tubing is changed weekly.The facility policy titled Oxygen Administration dated as revised 8/2/2024 read in part, Oxygen is administered to resident who need it, consistent with professional standards of practice, comprehensive person-centered care plans, and the resident's goals and preferences . 6. Cleaning and care of equipment shall be in accordance with facility policies for such equipment. There were no specifications in the policy as to when to change the oxygen tubing

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% for three Residents (R6, R7 & R 1) of 9 residents reviewed for medication administration. This deficient practice resulted in a medication administration error rate of 12.00%, based on 3 medication errors in 25 opportunities for error.Findings include:All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. Resident R21On 6/26/25 at 9:18 a.m., Registered Nurse (RN) A was observed preparing and administering medications on the 300 Hall medication cart. When preparing medications for R21, RN A punched out one 88 mcg (microgram) tablet of Levothyroxine that landed on top of the medication cart which had not been disinfected, nor was a barrier in place. RN A donned clean gloves without the performance of hand hygiene, picked up the tablet and placed it into R21's plastic medication cup for administration to the Resident.During an interview on 6/26/25 at 9:31 a.m., when asked if the top of the 300 Hall medication cart was clean or dirty, RN A stated, It is dirty. When asked what should have happened with the pill for R21, that was dropped onto the top of the medication cart, RN A stated, It should have been thrown away. RN A acknowledged a new pill should have been popped from the Levothyroxine blister pack and administered to R21.Resident R6On 6/26/25 at 12:09 p.m., RN B prepared Diclofenac Sodium (Voltaren) gel for application to R6's bilateral knees. RN B squeezed an undetermined amount in a 30 cc (cubic centimeter) medication cup. When asked what the Voltaren dosage was, RN B stated, 1 % When asked how much of the Voltaren gel was to be used. RN B said 4 grams. When asked if the amount in the medication cup was 4 grams, RN B was unsure. This Surveyor asked about the availability of a Dosing Card for the Voltaren. RN B said she had always placed the gel in the cup and was unaware of a dosing card, but said she would look for one. RN B examined the medication cart drawers, and did fine a Voltaren Dosing Card, which required review and education prior to proper application of the gel onto the card.Review of Voltaren Gel Dosage (Diclofenac Sodium 10 mg(milligrams) in 1 gram, last updated 8/22/24, revealed the following dosage instructions: .Dosing Care: The dosing card can be found attached to the inside of the carton. The proper amount of Voltaren Gel should be measured using the dosing card supplied in the drug product carton. The dosing card is made of clear polypropylene. The dosing card should be used for each application of drug product. The get should be applied with in the rectangular area of the dosing card up to the 2 gram or 4-gram line (2g for each elbow, wrist, or hand, and 4g for each knee, ankle, or foot) . The 4g line is 4.5 inches long. The dosing card containing Voltaren Gel can be used to apply the gel. The hands should then be used to gently rub the gel into the skin. After using the dosing card, hold with fingertips, rinse, and dry. Retrieved on 6/26/25 at 1:11 p.m. from drugs.com/dosage/voltaren-gel.html.Resident R7On 6/26/25 at 12:33 p.m., RN B prepared a Novolog Flexpen for administration of fast-acting insulin to R7. RN B primed the pen with 2 units of insulin, removed the needle, applied a clean needle and placed the insulin pen down on top of the medication cart. When asked why the needle had been changed on the insulin pen after priming, RN B stated, I don't know. I thought I was supposed to do that. RN B continued to look at this Surveyor, who then asked what RN B was going to do next. RN B asked, Prime the pen again? On 6/26/25 at approximately 12:35 p.m., RN B used the Novolog Flexpen to administer insulin into R7's right abdomen. RN B held the insulin pen in R7's abdominal skin [subcutaneously (SQ)] for 1-2 seconds; removing the pen quickly from the Resident. Review of the Novolog Instructions for Use, copyright 2023, revealed the following Novolog Flexpen insulin administration instructions: .Step 13: Press and hold down the dose button until the dose counter shows 0. Keep the needle in your skin after the dose counter has returned to ) and slowly count to 6. When the dose counter returns to 0 you will not get your full dose until 6 seconds later. If the needle is removed before you count to 6, you may see a stream of insulin coming from the needle lip . Document retrieved on 6/26/25 at 1:30 p.m., from novo-pi.com/novolog.pdf.During an interview on 6/26/25 at approximately 3:30 p.m., and 4:10 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed of the above medication preparation and administration errors. Both the NHA and DON expressed understanding of the deficiency concern related to the failure to maintain an error rate of less than 5%.

Based on interview and record review, the facility failed to consistently implement a bowel protocol program for one Resident (R32) of 2 Residents reviewed for bowel function in a total sample of 12 residents. This deficient practice resulted in extended periods of time when R32 had no documented bowel movement, with increased risk for pain and discomfort and/or the risk for medical complications such as bowel impaction. Findings include:All times recorded in Eastern Daylight Time (EDT), unless otherwise noted.A review of the medical record revealed that Resident #32 (R32) was admitted to the facility on [DATE] with diagnoses including chronic systolic congestive heart failure, protein-calorie malnutrition and encounter for palliative care. Review of R32's Minimum Data Set assessment, dated 5/22/25, revealed Section O (Special Treatments and Programs) noted R32 was on hospice care. The physician's orders for R32 included Fentanyl (a pain medication with known side effects of constipation).A review was conducted of R32's Task List for Bowel Continence for 5/28/25 through 6/26/25. The report revealed:- 5+ days (from 6/8/25 at 9:31 until 6/14/25 at 1:11 AM) without a recorded bowel movement- 4 days (from 6/16/25 at 1:59 PM until 6/20/25 at 9:24 PM) without a recorded bowel movement.- 5+ days (from 6/21/25 at 1:58 PM through today 6/26/25) without a recorded bowel movement.A review of Resident #32's Medication Administration Record (MAR) for the month of June 2025 revealed an order for Miralax, one packet . Give 1 packet by mouth every 24 hours as needed for constipation add to 4-8 ounces fluid Order date: 2/20/2025. The MAR had no documentation this medication for constipation was given in the month of June 2025.An interview was conducted with the Director of Nursing (DON) on 6/26/25 at 12:48 PM. The DON confirmed that there was no documentation on the June 2025 MAR for R32 getting Miralax for absence of bowel movements and constipation. The DON stated ,After 3 days without a BM (bowel movement) we would implement our bowel protocol. When asked for a copy of the bowel protocol one could not be presented.All times recorded in Eastern Daylight Time (EDT), unless otherwise noted.During an interview on 6/26/25 at 1:00 PM, the Nursing Home Administrator (NHA) and the DON stated there was protocol the Medical Director D used, but they had not implemented it at the time of the interview. The protocol was reviewed at that time, but the NHA and DON could not explain it and could not interpret the abbreviations (1 PR prn was thought to be a typographical error but was later explained by the Medical Director D as 1 per rectal as needed). During a follow up interview on 6/26/25 at 12:53 PM, the NHA confirmed there was not a current bowel policy in place in the facility at this time.During an interview on 6/26/25 at 1:12 PM, Medical Director D described the expectations for constipation in residents stating, The facility should call me to alert me when residents have not had a BM in 3 days. They should be giving Miralax per my order and then I will generally follow the protocol I gave to the facility. At this time, Medical Director D reviewed the medical record for R32, noting constipation of 5 days at the end of today. Medical Director D agreed the order for Miralax should have been followed as it had not been given as ordered all month. Medical Director D also noted R32 was on pain medications which frequently caused constipation. Medical Director D explained the expectation would be that the nurse would call her if any resident had not had a BM in three days and the resident did not have an order for measures to take.During an interview on 6/26/25 at 1:43 PM, Registered Nurse (RN) B stated if a resident did not have a BM in 3 days, she would follow the bowel protocol which involved Miralax, an enema and a suppository. RN B was not certain of the order of the actions to take. RN B stated, The protocol would indicate the order of these treatments. When asked to produce the protocol, RN B looked on the computer and could not locate it. RN B began to look through binders and papers at the nursing station. RN B did not locate a bowel protocol. When asked to check R32's last BM, RN B noted the last BM was 6/21/25, which was five days ago and RN B noted no action had been taken.

Based on observation, interview and record review, the facility failed to ensure the timely provision of ADL (Activities of Daily Living) care for two Residents (#31 and #25) of two residents reviewed for ADL care.Findings include:All times recorded in Eastern Daylight Time (EDT), unless otherwise noted.Resident #31 (R31)Review of the Minimum Data Set (MDS) assessment, dated 5/22/2025, revealed R31 was admitted to facility on 8/14/2024 and had diagnoses including diabetes, obstructive uropathy, peripheral vascular disease, morbid obesity, and depression. Further review of the MDS assessment revealed R31 had an indwelling urinary catheter, was always incontinent of bowel, required substantial/maximal staff assistance for toileting hygiene and bathing, and was dependent on staff for all transfers and mobility. R31 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he was cognitively intact. On 6/25/2025 at 8:59 a.m., an observation in the 300 Hall revealed the door to R31's room was closed. Upon entering, R31 was observed lying in bed covered by a white sheet from his torso to his shins, with his upper body and both lower legs and feet visible. It was noted R31's toenails were overgrown past the tip of the toes. Further observation revealed the nails of R31's great toes were grown out approximately one-half inch (in.) past the tip of the Resident's toes. Urinary catheter tubing was observed to lead from under the right side of the sheet to a dependent drainage bag attached to the right side of R31's bed frame. The drainage bag was not covered with a urinary drainage bag cover. It was noted that the drainage bag contained approximately 600 milliliters (ml) of dark, yellow urine and urine was visible in the tubing leading from the resident to the bag. There was an unpleasant fecal odor noted while standing near R31's bed.On 6/25/2025 at 10:55 a.m., R31's morning care was observed as provided by Certified Nursing Assistant (CNA) K and CNA N. CNA N was observed preparing to empty R31's urinary catheter drainage bag into a clear, graduated cylinder. It was noted the drainage bag appeared heavy and nearly full of dark, yellow urine. Further observation revealed CNA N filled the cylinder with urine from the bag, emptied the urine into the toilet in the Resident's bathroom, then returned to empty the remaining urine from the bag. CNA N reported she emptied 1,150 milliliters (ml) of urine from the drainage bag. After CNA N emptied the drainage bag, CNA K removed the sheet covering R31, and it was noted the Resident had been incontinent of bowel. Dried feces was observed on the white fitted sheet covering the mattress and feces was pooled on the absorbent pad positioned underneath the resident. CNA K washed R31's genitals then CNA N assisted R31 to lay on his left side while CNA K washed the stool from the resident buttocks and groin area. Further observation revealed areas of dried stool on the back of R31's upper thighs and buttocks. When asked when the last time the Resident was checked and changed, CNA N reported R31 requested not to be disturbed between 10:00 p.m. and 6:00 a.m. When asked if to clarify whether R31 had been checked and changed since 10:00 p.m. the previous evening, CNA N confirmed he had not been checked since he went to bed the previous evening. When asked about R31's toenail care, CNA N reported since the Resident was a diabetic, the CNA staff would alert the licensed nursing staff of the care needed and the licensed nurses would provide nail care.During an interview at the time of the observation, R31 reported he did not have control of his bowels and due to neuropathy, could not always feel when he was incontinent. R31 confirmed he did not like to be awakened in the middle of the night. When asked if anyone had been in to check this day after 6:00 a.m., R31 reported he received his breakfast, but no one checked to see if he was incontinent or if his catheter bag was full. R31 was asked when the last time staff trimmed his toes, he reported he was unsure but, More than a month ago.During an interview on 6/26/25 at 10:03 a.m., Licensed Practical Nurse (LPN) A was queried about the process for the provision of nail care for residents. LPN A reported the licensed nursing staff was responsible for nail care as the facility had no visiting podiatrist. When asked how often nail care is provided, LPN A stated the CNA staff are really good about letting us know it needs to be done . and we (licensed nurses) do it. Review of R31's comprehensive care plan revealed the following:I have diabetes mellitus . Inspect my feet daily . Date Initiated: 8/14/2024.It was noted in review, R31's care plan did not include a focus area or interventions related to R31's bowel incontinence, including how often the Resident needed to be checked or changed. There was no focus area or interventions related to nail care for the Resident with diabetes.On 6/26/25 at 2:51 p.m., the Director of Nursing (DON) was alerted to the observations of R31 and R25. The DON reported she expected staff to check for resident care needed at the beginning of each shift or as soon as possible. The DON reported she was aware of R31's request not to be disturbed in the middle of the night. When asked if R31 should be checked at the beginning of the morning shift due to not being checked all night and having a catheter and being incontinent. The DON reported it was important for staff to check on R31 early in the shift as he does not have control of his bowels and does not know when he has had a bowel movement. Resident #25 (R25)Review of the MDS assessment, dated 3/26/2025, revealed R25 was admitted to the facility on [DATE] and had diagnoses including prostate cancer, anemia and arthritis. Further review of the MDS assessment revealed R25 required substantial/maximal assistance with bathing and personal hygiene and had mild cognitive impairment. On 6/25/2025 at 8:40 a.m., R25 was observed in his room eating his morning meal. Further observation revealed R25's fingernails and nail beds to be visibly soiled with dark coloring under his nails and nailbed. His nails were noted to be unkempt, with jagged edges and the length of the nails grown out approximately one-half centimeter (cm) past the tip of his fingers.On 6/26/2025 at 3:02 p.m., R25 was observed seated in a recliner in his room. R25's fingernails were observed as previous. R25's nails were overgrown, and his right thumbnail was observed to be jagged with a sharp appearance. When asked if he would prefer to have his fingernails cleaned and trimmed, R25 stated, What can I do about it?Review of R25's comprehensive care plan revealed the following: I have an ADL self-care performance deficit . Personal hygiene/Oral care: Assist.Review of the facility policy titled, Activities of Daily Living (ADLs), last revised 7/15/2024, revealed the following:A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review, the facility failed to maintain facility living areas odor free and with comfortable temperatures for two Residents #7 and #31 (R7 and R31) of 16 residents reviewed for a safe, clean, comfortable environment. This deficient practice resulted in resident dissatisfaction with unbearably hot living conditions and the smell of urine in R7's room.Findings include: All times noted are Eastern Daylight Savings Time, unless otherwise noted. Resident #7 (R7) Review of R7's Minimum Data Set (MDS) assessment, dated 4/1/25, revealed R7 was admitted to the facility on [DATE], with diagnoses that included the following, in part: hypertension, end-stage renal disease, diabetes mellitus, dementia, and chronic obstructive pulmonary disease (COPD). R7 did not complete the Brief Interview for Mental Status (BIMS) but was documented with severely impaired cognition. R7 required Setup or clean-up assistance with upper body dressing, lower body dressing, putting on/taking off footwear (including socks), and personal hygiene. Review of R7's Progress Notes revealed the following, in part: 6/22/24 18:00 Central Daylight Savings Times (CDST)] LATE ENTRY: Writer continued to monitor resident and kept cooling washcloth to keep on head, resident was responding appropriately to writer stating she (R7) felt better but was still pale in color and was 'tired'. She was able to sip on OJ (orange juice and ice water at this time. POA (Power of Attorney) at bedside and states resident often doesn't drink enough water/fluids and has overheated before like this. She went to buy a resident a fan tonight for her room and states she feels comfortable with continuing to monitor and updating PCP (primary care provider) to see her this week at facility. Nursing staff to continue to monitor. Update was sent to PCP. 6/22/25 18:06 (6:06 CDST) Resident was lowered to the floor by CNA's (Certified Nurse Aides), she was walking in the hallway and began to faint . resident was transferred to her bed, she was changed into cooler clothing and a cool rag placed on her head. Resident's POA was called and she stated she is on her way here. Resident is responsive at this time but appears weak/exhausted. 6/24/25 13:52 (1:52 p.m. CDST) Residents room had a strong foul urine odor. She had a wet brief on the floor. She is weak today and required a wheelchair to get to the dining room. She was confused this morning at times. During a telephone interview on 6/25/25 at 3:05 p.m., Confidential Complainant C detailed the following information: One of the nurses called and told me [R7] had an episode . I said that you have to keep her cool because she has dementia and she will put on a million layers of clothes . I did not say that she had episodes like this before. When I arrived, they had her in bed. They had taken the multiple layers of clothing off. They told me she was wearing a long sleeve shirt, ted hose, long pants, a sweater, and thick socks . They had her in her bed with no pants, a brief, and a shirt . and a wet wash cloth draped over her forehead. I tried to wake her up, she tried to talk, and she would fall back asleep. I squeezed her finger tips trying to get her to open her eyes. Her door was open, when I arrived, The DON (Director of Nursing) had asked if we could purchase a fan for her. I had my spouse go to the dollar store and purchase the fan for her room . They said it is just the heat and when her body temperature cools, she will be okay. When I went in two days ago, she was still extremely tired, couldn't stay awake very long . Now she is much weaker. I had to have them give her a wheelchair because she can't walk without one . The only thing I have had a constant complaint about is that I will go in there and her room will smell like pee. Then they will come in and clean. I will go and she will have a pad with dry patches of circles of urine on it - there was one on her chair yesterday. That has been a constant. I told the social worker that either your aides have poor judgement, or they are just lazy . It was very hot in the facility, while we were in the room, there was sweat beading off of us just putting a fan together. In my opinion it was egregiously hot. [The DON] asked me to buy a fan. I didn't ask about having a fan .[The DON] said she did not believe they have fans for the resident rooms . During an observation and interview on 6/26/25 at 9:12 a.m. Certified Nurse Aide (CNA) E was asked to observe R7's chair and bedding. The odor of urine was clearly present in the room. The bed sheet was wet with urine. The sheets had not been removed after getting the resident up from bed to eat breakfast. When CNA E was asked if the odor of urine was present to her, CNA E stated, Oh yeah! and commented that the bed sheet was wet while the bed pad had been folder over with the blue water repellent side toward the resident. During an interview on 6/26/25 at 9:57 a.m., the DON said she was training a nurse on the other side of the facility when a resident came up and said my friend is not feeling good . She (R7) was pale, and it was hot that day (92-degree outdoor temperature) and she was dressed with thick compression stockings on, some tight leggings, her fuzzy socks on and a t shirt and a sweater on . I knew she was probably over heating - we got her into the wheelchair, some clothes off, got a cool cloth on her. I don't remember if her temperature was assessed. Her back was sweaty when we were putting her into the chair. I didn't take her temperature. She was not my resident . At that time, we knew we had to get the layers off . During an interview on 6/26/25 at 9:41 a.m., Environmental Services Director (ESD) G said he did not have any written documentation to show monitoring of facility temperatures on hot days in the facility. When asked how he would know if the temperature rose above 81 degrees in Resident rooms, ESD G stated, I would not know. The ESD G did acknowledged the outdoor temperature was 92 degrees on the day R7 required removal of clothing and cooling by facility staff. During an interview on 6/26/25 at 10:06 a.m., when asked if urine saturated bed sheets in R7's room should have been changed upon identification that they were wet, and the room smelled of urine, the DON stated, Absolutely they should be changed. Review of the Maintenance Director's Job Description, copyright 2023, signed on 9/19/24, revealed the following, in part: Position Purpose: Directs the day-to-day activities of the Maintenance Department in accordance with current federal, state, and local standards, guidelines and regulations governing the facility, and to assure the facility is maintained in a safe and comfortable manner. Resident #31 (R31)Review of the Minimum Data Set (MDS) assessment, dated 5/22/2025, revealed R31 was admitted to facility on 8/14/2024 and had diagnoses including obstructive uropathy, peripheral vascular disease, morbid obesity, and depression. Section GG indicated R31 required substantial/maximal staff assistance for toileting hygiene and bathing, and was dependent on staff for all transfers and mobility. R31 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating cognition was intact. On 6/25/25 at 8:59 a.m., an observation in the 300 Hall revealed the door to R31's room was closed. Upon entering, R31 was observed lying in bed covered by a white sheet from his torso to his shins, with his upper body and both lower legs and feet visible. When asked if he had any concerns regarding his stay in the facility, R31stated, Well, my current concern is with the heat. Resident stated, Over the past week there were a couple days where it (temperature) was unbearable in the facility. R31 reported the temperature in his room was overwhelming and that when he asked for a fan or for air conditioning to be turned on, was told the facility had neither available for use in resident rooms. When asked if it helped to have the door of his room open, R31 reported he preferred to have the door to his room closed for privacy. R31 reported he ordered a window air conditioner for his room, But, I'm not sure they'll let me use it.

Based on observation, interview and record review, the facility failed to provide a dignified care experience for two Residents (#31 and #14) of two residents reviewed for dignity, resulting in R31 expressing feelings of humiliation and helplessness.Findings include:All times recorded in Eastern Daylight Time (EDT), unless otherwise noted.Resident #31 (R31)Review of the Minimum Data Set (MDS) assessment, dated 5/22/2025, revealed R31 was admitted to facility on 8/14/2024 and had diagnoses including obstructive uropathy, peripheral vascular disease, morbid obesity, and depression. Further review of the MDS assessment revealed R31 had an indwelling urinary catheter, was always incontinent of bowel, required substantial/maximal staff assistance for toileting hygiene and bathing, and was dependent on staff for all transfers and mobility. R31 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he was cognitively intact. On 6/25/25 at 8:59 a.m., an observation in the 300 Hall revealed the door to R31's room was closed. Upon entering, R31 was observed lying in bed covered by a white sheet from his torso to his shins, with his upper body and both lower legs and feet visible. Urinary catheter tubing was observed to lead from under the right side of the sheet to a dependent drainage bag attached to the right side of R31's bed frame. The drainage bag was not covered with a urinary drainage bag cover. It was noted that the drainage bag contained approximately 600 milliliters (ml) of dark, yellow urine and urine was visible in the tubing leading from the resident to the bag. During an interview at the time of the observation, R31 reported he preferred to have the door to his room closed for privacy, but staff often walked into the room without knocking while care was being provided. R31 reported he did not often get out of bed and all care, including incontinence care and bathing were completed in his room. During the interview R31 expressed embarrassment that he was completely dependent on staff and that he felt helpless. On 6/25/2025 at 10:55 a.m., R31's morning care was observed as provided by Certified Nursing Assistant (CNA) K and CNA N. CNA N was observed emptying R31's urinary catheter drainage bag after which she performed hand hygiene in R31's bathroom. R31's bathroom was noted to be directly across from the end of the Resident's bed. CNA N then re-entered R31's room and left the bathroom door open. Continuing with care, CNA K pulled the sheet from R31, and it was noted the Resident had been incontinent of bowel. Dried feces was observed on the white fitted sheet covering the mattress and feces was pooled on the absorbent pad positioned underneath the resident. CNA K washed R31's genitals then CNA N assisted R31 to lay on his left side while CNA K washed the stool from the resident buttocks and groin area. While CNA K was cleansing stool from R31's buttocks, Resident #14 (R14), a female resident, was observed to enter the shared bathroom from the adjoining room. R31 was noted to still be without a covering with his exposed body in full view of R14. Upon noticing R14 through the open bathroom door, R31 sighed and stated, See, no privacy, this happens all the time, every time they start cleaning me up someone walks in. CNA N confirmed R14 resided in the adjoining room and shared the bathroom with R31. CNA K closed the bathroom door and left to assist R14. It was noted, neither CNA K or CNA N offered to cover or assisted R31 with a covering at any time during the care observation.On 6/25/2025 at 3:33 p.m., CNA K and CNA M were observed preparing R31 for a transfer from his bed to his recliner. Initial observation revealed R31 lying in bed wearing a disposable incontinence brief and his shorts pulled down to his mid-thighs, no other covering was present. R31 was rolled to the left then right as the CNAs pulled R31's shorts over his hips and buttocks then positioned the lift sling underneath the Resident. R31 was then transferred to the reclining chair. R31's bathroom door was noted to be ajar during the entire observation. During an interview on 6/26/2025 at 3:08 p.m., the Director of Nursing (DON) was informed of the observations involving R31. The DON confirmed R14 did share an adjoining bathroom with R31. The DON reported R31 did not physically use the bathroom as he was incontinent and had an indwelling urinary catheter, but staff did use the bathroom during his care provision. The DON reported it was important for staff to be sure the door is closed during R31's care to ensure his privacy and promote dignity for both R31 and R14.Review of the Michigan Long Term Care Ombudsman Program's, My Rights as a Resident of a Nursing Home accessed 6/26/2025, revealed the following: My right to dignity - I have a right to privacy when receiving care.

Based on observation, interview, and record review, the facility failed to honor the residents' rights to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect. This deficient practice affected all 36 residents residing in the facility.Findings include:All times recorded in Eastern Daylight Time (EDT), unless otherwise noted.On 6/25/25 at 11:00 AM, a confidential group meeting was held with six interested residents in attendance. The annual survey process was explained whereby a report would be sent to the facility with issues and concerns discovered by the State Agency. The facility would then respond in writing with a plan to correct the noted concerns. The entire report of both concerns and corrections would be public knowledge and must be posted in an easily accessible place in the building where the residents and others have the opportunity to read and review it. The residents in attendance did not know of this procedure and were unaware of the report's availability.The resident council president R3 stated agreed she did not know where the results of the last survey were posted.After the meeting on 6/25/25 at 11:27 AM, the public posting was sought out with R3. There was a binder with survey results hanging on the wall. However, the last survey of 5/14/24 was displayed with large print stamped Not Final on each page. There was not a plan of correction included.On 6/25/25 at 11:30 AM, the Nursing Home Administrator looked through the binder and confirmed there was not a final copy of the results of the last annual survey, and there was not a plan of correction for the concerns posted

Based on observation, interview, and record review, the facility failed to post the actual hours worked by licensed and unlicensed nursing staff on the daily Staff Posting Information.Findings include:All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. On 6/24/25 at 12:37 p.m., the Nurse Staffing Sheet was observed posted on the wall outside of the Social Workers office and across from the main nurses' station. A copy of the Nurse Staffing Sheet was requested and received from Activity Director O on 6/24/25 at 12:39 p.m. Review of Nurse Staffing Sheets dated 6/24, 6/25, and 6/26/25 revealed all columns for RN (Registered Nurse) Hours Actually Worked, LPN (Licensed Practical Nurse) Hours Actually Worked, and CNA (Certified Nurse Aide) Hours Actually Worked were blank: absent any documentation for all shifts.During an interview on 6/26/25 at approximately 3:30 p.m., the Nursing Home Administrator (NHA) was asked if she understood this Surveyor's concerns related to completion and posting of the Nurse Staffing Sheets. The Director of Nursing (DON) who was also present during the interview, asked the NHA what was wrong with the Nurse Staff Postings. The NHA stated, The actual hours worked (columns for all shifts) are blank.Review of the Nurse Staffing Posting Information policy, reviewed/revised 8/10/24, revealed the following, in part: Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time .1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility Name, b. The current date, c. Facility's current resident census, d. The total number of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses, ii. Licensed Practical Nurses/Licensed Vocational Nurses . 4. A copy of the schedule will be available to all supervisors to ensure the information posted is up-to-date and current. A. The information shall reflect staff absences on that shift due to call-outs and illness. After the start of each shift, actual hours will be updated to reflect such. b. Staffing shall include all nursing staff who are paid by the facility (including contract staff) .

Based on interview and record review, the facility failed to appropriately implement effective infection control measures to prevent the transmission of influenza A (a highly transmissible respiratory infection) resulting in three Residents (#33, #250 and #255) expiring in the facility due to influenza A with a total of 24 residents residing in the 39-bed facility becoming infected with influenza A. The facility failed to: 1) Promptly identify an outbreak of acute respiratory illness (influenza A). 2) Promptly implement transmission-based precautions for residents with signs and symptoms of acute respiratory illness (influenza A) to prevent the spread of infection. 3) Ensure prompt testing for communicable disease, including Covid-19, for residents with signs and symptoms of acute respiratory illness. 4) Ensure completion of an outbreak investigation and timeline. 5) Maintain a complete infection control program, including surveillance, mapping and monthly summaries. 6) Ensure the correct concentration of disinfectants were used in cleaning transmission-based precaution rooms. All times are recorded in eastern daylight time (EDT). This deficient practice resulted in Immediate Jeopardy (IJ) on [DATE], when two Residents (#21 and #34) developed signs and symptoms of respiratory illness within 72 hours of each other (Resident #21 on [DATE] and Resident #34 on [DATE]) and the facility failed to identify the outbreak and implement transmission-based precautions to prevent continued spread of influenza A, resulting in six more Residents (#27, #15, #3, #250, #18, and 6) contracting the illness prior to implementation of outbreak testing and transmission-based precautions on [DATE], with a total of 24 Residents contracting influenza A from [DATE] through [DATE]. The Nursing Home Administrator (NHA) was notified of the IJ on [DATE] at 10:45 a.m. The IJ was removed on [DATE] at 2:08 p.m. when the facility's abatement plan was approved and education was provided to the Director of Nursing (DON)/Infection Preventionist regarding the use of the Facility Outbreak Checklist, to ensure appropriate outbreak identification and tracking of infections within the facility. The facility's non-compliance remained at a widespread level due to the potential for more than minimal harm for all 36 residents in the facility while awaiting verification of the facility's plan of correction. Findings include: On [DATE] at 12:34 p.m., the DON reported being the Infection Preventionist for the facility. The DON presented a yellow binder containing the facility infection surveillance for [DATE] through [DATE]. The DON also presented a printed spreadsheet with Resident Infections [DATE] - present, written at the top. The DON stated the printed spreadsheet contained all resident infection surveillance for [DATE] to present ([DATE] at 12:34 p.m.). The DON reported the first date listed on each line was the date signs and symptoms of each infection began, followed by the resident name, type of infection and room number. It was noted there was no infection mapping or summary of resident infections included with the infection surveillance for [DATE] to present, provided by the DON. A review of the facility's infection surveillance document, titled Resident Infections [DATE] - present, revealed a running line-listing of resident infections from [DATE] to [DATE]. The document was not separated by month and did not include infection mapping to correspond to the line-listing or monthly summaries of the number and type of infections present within the facility for any given month. The line-listing did not include presenting symptoms or resolution date of infection. Further review of the document revealed 24 residents had the Type of Infection, listed as flu (influenza). The listing was not in chronological order and did not list room numbers for any of the residents listed as being infected with influenza. Further review revealed eight residents were listed with influenza A infection from [DATE] to [DATE] with another 16 residents listed with influenza A from [DATE] to [DATE]. There was no outbreak summary or investigation documents related to the influenza A outbreak from [DATE] through [DATE] included with the facility infection surveillance provided by the DON. There was no date of resolution listed on the line-listing to determine when the outbreak ended. During an interview immediately following review of the facility infection surveillance on [DATE], the DON confirmed there was no outbreak investigation or summary to correspond with the influenza A outbreak from [DATE] through [DATE]. When asked for the infection mapping to correspond with the line-listing, the DON stated the facility no longer formally mapped out the location of infections in the building because they were a small facility and mapping was not necessary. The DON stated three Residents (#32, #13 and #11) had been sent to the hospital for evaluation on [DATE] and upon calling to check on the Residents later that day ([DATE]), she was informed they all tested positive for influenza A. The DON stated all residents with respiratory infection signs and symptoms were placed in transmission-based precautions upon notification of the three Residents testing positive for influenza A on [DATE]. The DON confirmed she did not implement transmission-based precautions upon the first signs of respiratory illness when two residents (#21 and #34) had presented with like signs and symptoms within 72 hours of each other. The DON reported the health department contact, Registered Nurse (RN) Q was notified but gave no new instructions. The DON stated there was no documentation regarding her conversation with the health department regarding the facility outbreak of influenza A. The DON stated three Residents (#11, #32 and #13) had to be hospitalized due to infections with influenza A and three Residents (#33, #250 and #255) expired in the facility while being infected with influenza A. The DON was asked to provide a written timeline for the influenza A outbreak beginning [DATE]. Further review of the Resident Infections [DATE] - present, revealed Resident #21 was listed as having signs and symptoms of influenza on [DATE] and tested positive for influenza A on [DATE]. Resident #34 was listed as having signs and symptoms of influenza on [DATE] and tested positive for influenza A on [DATE]. A review of Resident #21's electronic medical record (EMR) revealed the following nurse's notes: [DATE] 13:14 (1:14 p.m. central daylight time [CDT]), Note: Resident having c/o cough. States it started last night in her nose and has progressed to what feels like postnasal drip making her cough . Resident states she just feels tired out today . [DATE] 10:02 (10:02 a.m. CDT), Note: Resident began having nasal congestion yesterday which seemed to develop into postnasal drip causing her to cough and yesterday just did not feel herself but felt very tired and not doing her usual activities . through the night resident had some nausea and woke up with increased incontinence noted . Today resident states she feels achy and again not herself and has little to nonproductive cough. States she is coughing up very little clear to white sputum . upon auscultation left lobes with faint expiratory wheezes and right lobe with rhonchi (abnormal lung sound indicative of fluid and/or inflammation in the lung) which is change from yesterday . At this point writer is concerned that this may be more respiratory related than [CONDITION(S)] (urinary tract infection) related. A review of Resident #34's EMR revealed the following nurse's notes: [DATE] 4:05 (4:05 a.m. CDT), Cough: productive, congested cough with large amount of thick clear phlegm . [DATE] 11:52 (11:52 a.m. CDT), C/O Health: coughing, chills, rib discomfort . The following Residents were also listed on the Resident Infections [DATE] - present, as having signs and symptoms of influenza prior to [DATE]: Resident #27 - [DATE] Resident #15 - [DATE] Resident #3 - [DATE] Resident #6 - [DATE] Resident #250 - [DATE] Resident #18 - [DATE] During an interview on [DATE] at 8:10 a.m., the Nursing Home Administrator (NHA) reported he was aware of the influenza A outbreak identified on [DATE]. The NHA stated he was unaware eight residents had signs and symptoms of respiratory illness prior to [DATE], from [DATE] through [DATE], and prior to the initiation of transmission-based precautions. When asked if the outbreak had been reviewed by the facility's QAPI (Quality Assurance Performance Improvement) Committee, the NHA stated infection control issues were reviewed quarterly by the QAPI Committee. The NHA reported the last QAPI meeting occurred on [DATE] but since the outbreak occurred after that last quarterly meeting on [DATE], the outbreak would be discussed at the next quarterly QAPI meeting in June. During a telephone interview on [DATE] at 2:00 p.m., Health Department Contact, RN Q reported she had become aware of the influenza outbreak at the facility on [DATE] upon notification from the facility Medical Director, Physician (MD) G. RN Q stated she had been contacted by MD G several times in the days following the initial contact on [DATE]. RN Q stated MD G was very concerned about the outbreak at the facility and after being contacted by MD G several times, she contacted the DON to verify the information received by MD G. RN Q confirmed she had not been previously contacted by the facility regarding an outbreak of respiratory illness prior to being contacted by MD G on [DATE]. During an interview on [DATE] at 2:16 p.m., MD G reported she was aware of the influenza A outbreak occurring in the facility. MD G stated she had been very concerned for the residents as many of the residents were in fragile health and she had never seen so many affected by influenza A at the same time. MD G reported she contacted RN Q to alert her to the outbreak on [DATE]. MD G stated she sent three Residents (#32, #13 and #11) out to the hospital related to worsening respiratory symptoms and low oxygen levels and three Residents (#33, #250 and #255) expired in the facility from influenza A during the outbreak period. A review of the written outbreak timeline provided by the DON on [DATE] at 4:45 p.m., titled Influenza Outbreak Investigation, revealed the following: [DATE] - First resident with symptoms. tested for COVID and was negative this day. All residents going forward with symptoms were tested . [DATE] - Another resident with symptoms, all group dining and activities stopped. Instructed staff to encourage residents to stay in their rooms if at all possible and if they are agreeable. [DATE] - Two residents sent to hospital, confirmed influenza A there, all symptomatic residents placed in droplet isolation. Dial My Call message sent to all staff and resident responsible parties that influenza A was identified in building. (MD G) notified, who call(ed) health department and health department call(ed) DON with questions - they gave no new recommendations other that isolating ill residents, stopping group dining and activities. The DON stated she had just typed the Influenza Outbreak Investigation, to present to this Surveyor. Further review revealed no residents were identified on the investigation form and no resolution date for the influenza A outbreak was noted. The DON reported the NHA was working on a new line-listing, to include the specific details of each effected resident's signs and symptoms along with the date of resolution. The DON stated she was working on retrieving the details from each resident's medical record to record on the line-listing. The DON could not answer to when the outbreak ended. The death certificates for Residents #33, #250 and #255 were requested at that time. Further review of the document titled Resident Infections [DATE] - Present, revealed the following: Resident #33 was listed with signs and symptoms of acute respiratory illness on [DATE] and tested positive for influenza A on [DATE]. Resident #250 was listed with signs and symptoms of acute respiratory illness on [DATE] (as referenced previously) and tested positive for influenza A on [DATE]. Resident #255 was listed with signs and symptoms of acute respiratory illness on [DATE] and tested positive for inluenza A on [DATE]. On [DATE] at 7:45 a.m., a review of the requested death certificates revealed the following cause of death listed for each Resident: Resident #33 - date of death : [DATE] . 35. Part I . a. (Due to or as a consequence of) Influenza A. Resident #250 - date of death : [DATE] . 35. Part I . a. (Due to or as a consequence of) Influenza A. Resident #255 - date of death : [DATE] . 35. Part I . a. (Due to or as a consequence of) Influenza A. During a follow-up interview on [DATE] at 11:22 a.m., MD G was asked to give an account of the timeline for the outbreak of influenza A that began on [DATE]. MD G stated she had called the facility on the morning of [DATE] to check on the status of a resident concerning a possible [CONDITION(S)] (DVT). MD G reported upon speaking to the nurse on duty, RN M notified her everyone is coughing here. MD G confirmed she received no notification from the DON or other nursing staff of eight residents showing signs and symptoms from [DATE] through [DATE] or of any residents showing signs and symptoms of respiratory illness prior to calling the facility on [DATE]. MD G stated arrived at the facility to find six residents in respiratory distress requiring her to transfer three residents to the hospital to receive a higher level of care. MD G stated she tested all residents in the facility at that time for COVID-19 and phoned RN Q at the health department. MD G confirmed upon her arrival to the facility on [DATE], no residents with signs and symptoms of respiratory illness were in transmission-based precautions. A review of the QAPI/Quality Meeting, summary, dated [DATE] and provided by the NHA, revealed the following, in part: Agenda Item - Resident Incidents: Acute Changes: 30 (24 influenza). Sent to Hospital: 5 (3 for influenza .). Further review revealed no actions had been taken regarding the facility outbreak of influenza A and no Infection Control items were listed on the agenda as reviewed at the [DATE] QAPI/Quality Meeting. A review of the facility policy titled Infection Control Plan, dated [DATE], revealed the following, in part: Purpose: (Facility Name) will maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. The goals of the Infection Control Plan are to monitor, investigate, control and prevent nosocomial infections, keep residents and staff safe through proper isolation and transmission reducing plans and maintain a record of infections and follow up investigations . Infection Control Committee - The QAA/QAPI committee will act as the Infection Control Committee . The Infection Control Committee will conduct all of the following activities and will submit periodic reports and recommendations for change to the governing body, or owner . a. Provide surveillance management to detect the presence of communicable disease or infection . A review of the Centers for Disease Control and Prevention's (CDC) guideline titled Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities, revealed the following, in part: Even if it's not influenza season, influenza testing should occur when any resident has signs and symptoms that could be due to influenza, and especially when two residents or more develop respiratory illness within 72 hours of each other .Note that older adults and other long-term care residents, including those who are medically fragile and those with neurological or neurocognitive conditions, may manifest atypical signs and symptoms of influenza virus infection (e.g. behavior change), and may not have fever. Determine if influenza virus is the causative agent by performing influenza testing on upper respiratory tract specimens (i.e. nasopharyngeal swab, nasal swabs, nasopharyngeal or nasal aspirates, or combined nasal and throat swabs) of ill residents with recent onset of signs and symptoms suggestive of influenza or acute respiratory illness . Adhere to Droplet Precautions: Droplet precautions should be implemented for patients with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a patient is in a healthcare facility . Based on observation and interview, and record review the facility failed to ensure proper concentration of disinfectants were used by housekeeping services for Transmission Based Precaution (TBP) resident rooms. This deficient practice has the potential to result in the transmission of infectious organisms to all 36 residents in the facility. Findings include: On [DATE] an interview with Housekeeping supervisor (HK) A was conducted related to the use of disinfectants used for cleaning TBP resident rooms. A gallon container was observed in the housekeeping closet, at the sink connected to a mixing dispenser. The gallon container's label identified the disinfectant as a quaternary ammonium (quat) product. HK A was asked what the target concentration of the quat was required to disinfect a TBP room. HK A stated she did not know. when asked if testing procedures were used to determine the concentration, once mixed, HK A stated the vendor supplying the chemical did not provide any. A review of facility Policy #:140.70 Environmental Cleaning Procedure dated [DATE] was conducted. Paragraph 12 identifies C. Difficile as the only TBP type room and specifies the used of hypochlorite (,d+[DATE] ppm) or [MEDICATION(S)] (4.5%). HK A stated these products were not used.

Based on observation, interview and record review, the facility failed to appropriately assess and provide treatment and services to prevent the development of a pressure injury for one Resident (#23) of one resident reviewed for pressure injuries. This deficient practice resulted in harm when Resident #23 developed a new, facility-acquired Stage 3 (full-thickness tissue loss) pressure injury. Findings include: All times recorded in eastern daylight time (EDT). A review of Resident #23's most recent Minimum Data Set (MDS) Assessment, dated 3/16/2022, revealed Resident #23 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MDS Assessment revealed Resident #23 required one-person physical assistance with bed mobility and two-person physical assistance with transfers, toileting and personal hygiene. Resident #23 scored 00 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. A review of Section M - Skin Conditions revealed Resident #23 was assessed as not at risk for development of pressure injuries and had no unhealed pressure injuries as of the date of the assessment on 3/16/2022. An observation of Resident #23's wound care provided by Licensed Practical Nurse (LPN) L on 5/11/2022 at 10:42 a.m., revealed an unstageable pressure injury on Resident #23's left ischial tuberosity (part of the hip bone one sits on). Further observation revealed the wound was approximately 0.5 centimeters (cm) long by 0.5 cm wide. The edges of the wound were indurated (raised) and white in color. LPN L reported the edges of the wound were macerated (loss of pigmentation due to excessive moisture). The wound bed could not be visualized due to the depth of the wound. During an interview immediately following the observation, LPN L confirmed she could not visualize the wound bed and did not measure the depth of the wound or assess for tunneling. A review of Resident #23's wound care assessment for the wound care observed on 5/11/2022 at 10:42 a.m. and provided by the Director of Nursing (DON), revealed LPN L measured the wound to be 0.5 cm long by 0.5 cm wide with moderate, yellow drainage. LPN L documented the wound tissue type as granulation (healthy, pink tissue). Further review of LPN L's wound care assessment for Resident #23 revealed LPN L had documented the wound edges were macerated and not flush with the wound surface. It was noted the depth of the wound was documented as, packed with 0.5 cm of (antimicrobial gauze strip). It was noted there was no measurement of the depth or assessment for tunneling for Resident #23's pressure ulcer. A review of Resident #23's skin assessments from January 2022 through May 8, 2022, provided by the DON revealed the following: 3/21/2022 15:37 (3:37 p.m. central daylight time [CDT]}: no pressure ulcers. 3/31/2022 9:50 (9:50 a.m. CDT): no pressure ulcers. 4/8/2022 4:49 (4:40 a.m. CDT): Resident has an abrasion to her left lower buttock. Area cleansed and medi-honey and [MEDICATION(S)] applied. Treatment started. It was noted there were no measurements or description on Resident #23's wound documented on the 4/8/2022 skin assessment. 4/20/2022 9:32 (9:32 a.m. CDT): Location: Left Buttock. Description - Area: length (cm): 1.3, width (cm): 1.5, depth: 0.2 . Tissue Type Score: slough (yellow/white coating covering all or part of the wound bed indicative of full-thickness tissue loss [Stage 3 or Stage 4 pressure ulcer]). 10:08 (10:08 a.m. CDT): Pressure Ulcer: Partial thickness loss of skin layers that presents as an abrasion or blister. Pressure Stg. 2. 4/21/2022 8:15 (8:15 a.m. CDT): Ordered treatment completed to stage 2 pressure ulcer to resident's lower left buttock. Measurements taken 1.3 cm x 1.5 cm x 0.2 cm. Wound bed with slough noted . Resident currently has a padded wheelchair cushion but will change this to a roho cushion at this time to decrease pressure . 10:46 (10:46 a.m. CDT): Pressure Ulcer: Partial thickness loss of skin layers presents as an abrasion or blister (Pressure Stg. 2) Pressure Ulcers on Admit: No pressure ulcers on admit. Pressure Ulcer Hx: 2 weeks old . 5/02/2022 9:13 (9:13 a.m. CDT): Left lower buttock stage 2 pressure ulcer . tissue surrounding with no (signs or symptoms) of infection noted . Open area is decreasing in size and about the size of a pea. Wound bed appears with yellow slough at this [NAME] . 5/04/2022 11:13 (11:13 a.m. CDT): Left Buttock. Length (cm): 1.0, width (cm): 0.5, depth: .03, Exudate among: Moderate, Tissue Type . Granulation (health, pink tissue) . 5/05/2022 9:07 (9:07 a.m. CDT): . Yesterday's measurements indicated the depth of the wound was 0.2 cm. Upon this writer's assessment, it was noted that some tunneling appeared to be present at approximately 3 o'clock position with some green drainage noted . tunneling went down about 1.5 cm with greenish-yellow drainage present . previously the wound appeared to be a stage 2 pressure ulcer but now with the presence of tunneling writer would put the current stage at 3. During the record review it was noted there were no wound assessments documented from 4/08/2022 (abrasion to left buttock) until 4/20/2022 (stage 2 pressure ulcer with slough). During an interview on 5/12/2022 at 7:38 a.m., the DON reported she was aware of the pressure ulcer located on Resident #23's left ischial tuberosity. When asked why the wound had not been deemed unstageable upon the assessment of slough in the wound bed on 4/20/2022, the DON stated some of the facility nurses were not comfortable with wound assessments and wound care documentation. The DON reported the facility had been conducting education for nursing staff of wound care and assessment of wounds. The DON reported all wound measurements should documented, including any tunneling and the depth of the wound, using the facility's wound care assessment tool (PUSH Tool). A review of Resident #23's care plan with the DON revealed no interventions had been in place related to the Resident's risk of developing pressure ulcers prior to the appearance of the Resident's pressure ulcer on 4/08/2022. The DON confirmed Resident #23 had severe dementia, required staff assistance to reposition and transfer, and could not purposefully reposition herself in bed or while up in a wheelchair prior to and after the development of the pressure ulcer on 4/08/2022. When asked if it was appropriate that Resident #23's wound was classified as a stage 2 pressure ulcer after the appearance of slough in the wound as documented on 4/20/2022, the DON was unable to answer. A review Resident #23's most recent Braden Assessment, dated 3/21/2022 and provided by the DON, revealed Resident #23 was scored as having a mild risk for development of pressure ulcers. It was noted Resident #23 had not been assessed for risk since 3/21/2022 and following the identification of the Resident's pressure ulcer on 4/08/2022. A review of the Wound Care Education Institute (WCEI) document titled Is it a Pressure Wound, updated 5/2021, revealed the following, in part: . Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present . 1) Partial thickness - Damage to epidermis, dermis, or both 2) Shiny or dry shallow open area with a red, pink wound bed, without slough or bruising. Slough is made up of dead collagen matrix from the subcutaneous tissue. The presence of slough indicates full thickness tissue damage .' A review of the facility policy titled Wound Care Prevention and Nutrition Assessment, dated 12/07/2021, revealed the following, in part: Purpose: To provide clear direction on assessment and intervention for resident with existing wounds and/or high risk of skin breakdown . 2. Following admission, a Braden Scale will also be performed on each resident quarterly, annually, and with significant change in condition . 7. Residents who are unable/unwilling to easily reposition themselves with be repositioned every 2 hours while in bed or in chair unless care plan indicates otherwise .

Based on observation, interview, and record review, the facility failed to provide appropriate assist for transferring in one (Resident #50) in four residents reviewed for accidents. This deficient practice resulted in a [MEDICAL CONDITION] tibia for Resident #50. Findings include: The facesheet of Resident #50 revealed the resident was a ninety-six-year-old who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of 08/15, indicating moderate cognitive impairment. On 7/10/18 at 2:48 pm, Resident #50 was observed laying in her bed with the head of the bed elevated, bilateral grab bars in place, and the resident was wearing an oxygen nasal canula, which was providing 2 liters of oxygen. This Surveyor asked Resident #50 if she recalled how her leg was broken. Resident #50 replied, I don't know, it don't hurt now. The resident could not recall what happened to her leg. Resident #50's RESIDENT CARE PLAN INFORMATION, an undated document, had CP (care plan) prior to fall hand-written on it, was given to this Surveyor on 7/10/18 at 3:15 p.m. This document revealed, TRANSFER: Mechanical Lift Only, and MECHANICAL LIFT: (brand name) 2 Assist (use double bar lift only). A document titled, INVESTIGATIVE SUMMARY REPORT, dated 7/6/18, revealed a statement, written by Certified Nurse Aide (CNA) A: I was transferring (Resident #50) from the toilet to the weight chair . with the straight bar (brand name) lift. After toileting, I pulled up her pants, set her on shower room lift chair so that her feet were not touching and asked her to let go of the bar. The lift straps remained hooked to the machine (mechanical lift) but I wanted her feet raised and her not holding the bar in order to get an accurate weight. Before I could even get the weight the resident seemed to panic, grabbed the bar and started to kick her feet So I hurried and lowered the lift. But then her feet were no longer over the bottom of the lift rather they were on the bathroom floor right behind the lift. They were not flat or straight. I yelled for help and co-workers and I lowered her back in the weight chair. At first she was complaining about pain in her ribs. We attempted to stand her with the (mechanical lift) twice but she said it hurt too bad around her stomach. She then said her knee hurt so we lifted her pants and her knee appears to have been injured. We put a hoyer lift pad under her and lowered her to the floor. In an interview with CNA A on 7/10/18 at 2:56 p.m., she stated, Can I grab a (brand name) lift so I can show you? and left to get the lift. CNA A brought the lift into the 100 wing shower room and proceeded to tell this Surveyor what happened. I put her (Resident #50) in the seat (outside of the whirlpool) and raised her up so her feet were off the (mechanical lift) foot pad. She panicked or something, when she let go of the bar, and grabbed it and it moved away so I lowered her quickly, then noticed her feet were not on the pad but behind her, and I thought maybe her ankle was hurt. I hollered for help and we raised her up (still in the whirlpool chair/seat) but she hollered, so we thought maybe it was her ribs, so we lowered her to put the hoyer pad under her and that's when she yelled out when we moved her leg and noticed it was swollen and turning purple, so we lowered her to the floor. There was a seatbelt-type of strap on the side of the whirlpool chair/seat, with a looped strap in the front and a buckle on the other side of the chair. When asked if she used this to secure the resident, CNA A stated she'd never used that before, and added, I probably should have. When asked if the wheels were locked on the mechanical lift, CNA A stated yes, and demonstrated locking the wheels. This Surveyor tried to push the mechanical lift while it was locked, and it wouldn't move. When asked if she would transfer the resident again herself, CNA A stated, No, I would get another aide to help me. In an interview with Licensed Practical Nurse (LPN) B, she stated, I heard a scream. I was the third nurse in there, (Resident #50) was kind of hanging from the (mechanical lift) strap and crumpled on the floor with her legs in an awkward position. No, she wasn't on the whirlpool seat at that time. We thought she was hurt around her rib cage where the strap is, but she said, my knee and was crying. So we looked at the left knee, it wasn't good-very swollen, so I went and got a nurse to assess her, and then everything happened very quickly after that. When asked about Resident #50's life before the injury, LPN B stated, (Resident #50) would be in this room (conference room) when family came to visit, and she would be in her wheelchair to go to different activities. She didn't go to them all, but the ones she wanted to. Yes, she'd be up in her wheelchair unless she was taking a nap. Registered Nurse (RN) C was asked if anything has changed for the resident since her injury, RN C stated, The doctor has put her on bedrest right now. Things have changed for her, we have her on pain control. We had her on [MEDICATION NAME] tablets. Her mood is good now, the old (Resident #50), but as far as her movement, yeah, that has changed. In an interview with the DON on 7/11/18 at 9:38 a.m., she stated, Yes, it was an accident, but it was poor judgement on the part of the CNA. When I asked (CNA A) why she didn't use two (people) for the transfer, she said she didn't realize she needed two all the time, she thought it was just sometimes, even though it says it right on the care plan.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEWS, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT AN ACCIDENT FOR ONE (#1) OF FOUR RESIDENTS REVIEWED WHO WERE AT RISK FOR FALLING. THIS FAILURE RESULTED IN THE RESIDENT (#1) HAVING REPEAT FALLS WITH SUBSEQUENT FRACTURE OF THE HIP. FINDINGS INCLUDE: A REVIEW OF RESIDENT #1'S MEDICAL FILE REVEALED RESIDENT #1 IS AN [AGE] year OLD MAN WHO WAS admitted to the facility on [DATE]. HIS [DIAGNOSES REDACTED]. HIS MEDICATIONS INCLUDED, BUT WERE NOT LIMITED TO THE HIGH BLOOD PRESSURE MEDICATION ACCUPRIL AND THE DIURETIC MEDICATION HYDROCHLOROTHIAZIDE. A REVIEW OF THE RESIDENT'S MEDICAL RECORD SHOWED ON 4/26/11 AT 3:24 P.M., THE FACILITY COMPLETED A FALL RISK ASSESSMENT FOR RESIDENT #1. IT IDENTIFIED MEDICATION CATEGORIES ASSOCIATED WITH INCREASED RISK FOR FALLS INCLUDING ANTIHYPERTENSIVES (SIDE EFFECTS: DIZZINESS, LIGHTHEADEDNESS, FAINTING, HYPOTENSION) AND DIURETICS (SIDE EFFECTS: POSTURAL HYPOTENSION, FATIGUE). THE ASSESSMENT SHOWED RESIDENT #1 WAS DETERMINED TO BE AT HIGH RISK FOR FALLS AND A FALL RISK CARE PLAN WAS IMPLEMENTED. A REVIEW OF RESIDENT #1'S FALL CARE PLAN DATED 4/26/11, REVEALED THAT HIS POTENTIAL FOR TRAUMA-FALLS WAS RELATED TO INCONTINENCE AND A DECLINE IN COGNITIVE STATUS. THE SIDE EFFECTS OF THE ANTIHYPERTENSIVE OR DIURETIC MEDICATIONS RESIDENT #1 WAS RECEIVING WERE NOT LISTED, NOR WAS THE RESIDENT'S INCREASED RISK FOR FALLS RELATED TO THESE MEDICATIONS ADDRESSED. A REVIEW OF RESIDENT #1'S HYPERTENSION CARE PLAN DATED 4/26/11, REVEALED THAT IT WAS MANIFESTED BY ELEVATED BLOOD PRESSURE. THE INTERVENTIONS (APPROACHES) LISTED WERE: MONITOR BLOOD PRESSURE, REPORT COMPLAINTS OF HEADACHE, REPORT DIZZINESS, ELEVATE FEET/LEGS AND NOTE EDEMA, WITH THE GOAL BEING NO SUSTAINED ELEVATED BLOOD PRESSURE. NEITHER OF THESE CARE PLANS INCLUDED INTERVENTIONS TO EITHER MONITOR RESIDENT #1 FOR THE SIDE EFFECTS OF ANTIHYPERTENSIVE MEDICATIONS (LIGHTHEADEDNESS, FAINTING, HYPOTENSION) OR DIURETIC MEDICATIONS USED TO TREAT HYPERTENSION (POSTURAL HYPOTENSION, FATIGUE) THAT THE FACILITY HAD IDENTIFIED IN RESIDENT #1'S FALL RISK assessment dated [DATE]. NOR WERE INTERVENTIONS PROVIDED TO THE CARE PROVIDERS DESCRIBING METHODS TO REDUCE THE RISK FOR FALLING AS A RESULT OF POSTURAL HYPOTENSION, SUCH AS DANGLING AT THE BEDSIDE, ASSISTING THE RESIDENT TO STAND UPON RISING, ETC. A REVIEW OF RESIDENT #1'S COMPUTER GENERATED BLOOD PRESSURE READINGS SHOWED THAT BETWEEN 4/26/11 AND 5/2/11, HIS SYSTOLIC BLOOD PRESSURE RANGED BETWEEN 100-128 MILLIMETERS OF MERCURY (MMHG) AND HIS DIASTOLIC BLOOD PRESSURE RANGED BETWEEN 60-84MMHG, WITH THE EXCEPTION OF THREE OCCASIONS (4/28/11, 4/29/11 AND 5/1/11) WHEN HIS BLOOD PRESSURE WAS LOW AT 92/60MMHG, 88/42MMHG, AND 96/52MMHG RESPECTIVELY. NONE OF THE READINGS RECORD WHETHER THE RESIDENT WAS IN A SITTING, STANDING, OR LYING POSITION WHEN THE BLOOD PRESSURES WERE TAKEN. DURING THE SURVEY ON 6/6/11 AT 12:30 P.M. EASTERN DAYLIGHT TIME (EDT), LICENSED PRACTICAL NURSE (LPN) 'B' WAS OBSERVED TAKING RESIDENT #1'S BLOOD PRESSURE AS HE WAS SEATED IN HIS WHEELCHAIR. TWO READINGS ON HIS LEFT ARM WERE 98/46MMHG AND 96/48MMHG; ONE READING ON HIS RIGHT ARM WAS 92/41MMHG. WHEN ASKED WHEN SHE WOULD REPORT AN ABNORMAL BLOOD PRESSURE READING TO THE PHYSICIAN, SHE STATED, "SOMETIMES THERE ARE DOCTOR'S ORDERS WITH PARAMETERS, BUT I DON'T BELIEVE SO FOR THIS RESIDENT. I WOULD REPORT ANYTHING BELOW 100MMHG SYSTOLIC OR 50MMHG DIASTOLIC." RESIDENT #1'S BLOOD PRESSURE READING ON 5/1/11 (96/52) WAS ENTERED INTO THE COMPUTER AT 1:08 P.M. THE NURSING NOTES REVEALED THAT LATER THAT DAY AT 3:00 P.M., "A VISITOR SAID SHE SAW RESIDENT (#1) TRY TO STAND FROM THE WHEELCHAIR AND RESIDENT'S KNEES BUCKLED AND RESIDENT SLID TO FLOOR." FURTHER REVIEW OF THE RESIDENT RECORD REVEALS THAT ON 5/2/11, AFTER RESIDENT COMPLAINED OF RIGHT HIP AND GROIN PAIN, HE WAS TRANSFERRED TO THE emergency room AND admitted to the hospital with [REDACTED]. THE HOSPITAL'S ATTENDING PHYSICIAN WROTE IN HIS HISTORY AND PHYSICAL DATED 5/2/11, "THE PATIENT SUSTAINED A FRACTURE status [REDACTED]. THE 5/7/11 DISCHARGE SUMMARY FROM THE HOSPITAL READS IN PART, "HYPOTENSION DURING THIS ADMISSION ATTRIBUTED TO DEHYDRATION RESPONDED WELL WITH IV FLUID." THE HOSPITAL DISCHARGE SUMMARY ALSO SHOWED RESIDENT'S #1'S BLOOD PRESSURE MEDICATIONS WERE LOWERED WITH ACCUPRIL CUT TO HALF THE PREVIOUS DOSE, AND A LOW DOSE OF METOPROLOL STARTED. THE DIURETIC HYDROCHLOROTHIAZIDE WAS DISCONTINUED. A FURTHER REVIEW OF RESIDENT #1'S CARE PLANS SHOWED THAT, ALTHOUGH THE FALL CARE PLAN WAS UPDATED ON 5/9/11, IT STILL DID NOT IDENTIFY THE NEED FOR MONITORING OR SPECIFIC INTERVENTIONS FOR THE POTENTIAL SIDE EFFECTS OF ANTIHYPERTENSIVE MEDICATIONS. ADDITIONALLY, THE RECORD FOR RESIDENT #1 SHOWED HE HAD A SECOND FALL. ACCORDING TO THE INCIDENT CHARTING (ENTERED ON 5/23/11 AT 8:36 P.M.), RESIDENT #1 WAS FOUND "SITTING ON THE FLOOR IN HIS ROOM BETWEEN THE BEDS, CHAIR WAS IN THE DOORWAY" ON 5/23/11 AT 2:12 P.M. THIS CHARTING ALSO READS, "(IMMEDIATELY AFTER) BLOOD PRESSURE 104/52." ACCORDING TO THE FACILITY ACCIDENT/INCIDENT REPORT DATED 5/24/11, THERE WAS NO APPARENT INJURY. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEWS, THE FACILITY FAILED TO DEVELOP A PLAN OF CARE WITH SPECIFIC INTERVENTIONS (RELEVANT TO THE POTENTIAL SIDE EFFECTS OF PRESCRIBED ANTIHYPERTENSIVE AND DIURETIC MEDICATIONS) NECESSARY TO MINIMIZE THE RISK OF FALLING FOR ONE (#1) OF FOUR RESIDENTS REVIEWED WHO WERE AT RISK FOR FALLING. THIS FAILURE RESULTED IN RESIDENT (#1) HAVING REPEAT FALLS WITH SUBSEQUENT [MEDICAL CONDITION]. FINDINGS INCLUDE: A REVIEW OF RESIDENT #1'S MEDICAL FILE REVEALED RESIDENT #1 IS AN [AGE] year OLD MAN WHO WAS admitted to the facility on [DATE]. HIS [DIAGNOSES REDACTED]. HIS MEDICATIONS INCLUDED, BUT WERE NOT LIMITED TO THE HIGH BLOOD PRESSURE MEDICATION [MEDICATION NAME] AND THE DIURETIC MEDICATION [MEDICATION NAME]. A REVIEW OF THE RESIDENT'S MEDICAL RECORD SHOWED ON 4/26/11 AT 3:24 P.M., THE FACILITY COMPLETED A FALL RISK ASSESSMENT FOR RESIDENT #1. IT IDENTIFIED MEDICATION CATEGORIES ASSOCIATED WITH INCREASED RISK FOR FALLS INCLUDING ANTIHYPERTENSIVES (SIDE EFFECTS: DIZZINESS, LIGHTHEADEDNESS, [MEDICAL CONDITIONS]) AND DIURETICS (SIDE EFFECTS: POSTURAL [MEDICAL CONDITION], FATIGUE). THE ASSESSMENT SHOWED RESIDENT #1 WAS DETERMINED TO BE AT HIGH RISK FOR FALLS AND A FALL RISK CARE PLAN WAS IMPLEMENTED. A REVIEW OF RESIDENT #1'S FALL CARE PLAN DATED 4/26/11, REVEALED THAT HIS POTENTIAL FOR TRAUMA-FALLS WAS RELATED TO INCONTINENCE AND DECLINE IN COGNITIVE STATUS. SIDE EFFECTS OF ANTIHYPERTENSIVE OR DIURETIC MEDICATIONS WERE NOT LISTED, NOR WAS THE RESIDENT'S INCREASED RISK FOR FALLS RELATED TO THESE MEDICATIONS ADDRESSED. A REVIEW OF RESIDENT #1'S HYPERTENSION CARE PLAN DATED 4/26/11, REVEALED THAT IT WAS MANIFESTED BY ELEVATED BLOOD PRESSURE. THE INTERVENTIONS (APPROACHES) LISTED WERE: MONITOR BLOOD PRESSURE, REPORT COMPLAINTS OF HEADACHE, REPORT DIZZINESS, ELEVATE FEET/LEGS AND NOTE [MEDICAL CONDITION], WITH THE GOAL BEING NO SUSTAINED ELEVATED BLOOD PRESSURE. NEITHER OF THESE CARE PLANS INCLUDED INTERVENTIONS TO EITHER MONITOR RESIDENT #1 FOR THE SIDE EFFECTS OF ANTIHYPERTENSIVE MEDICATIONS (LIGHTHEADEDNESS, [MEDICAL CONDITIONS]) OR DIURETIC MEDICATIONS USED TO TREAT HYPERTENSION (POSTURAL [MEDICAL CONDITION], FATIGUE) THAT THE FACILITY HAD IDENTIFIED IN RESIDENT #1'S FALL RISK ASSESSMENT, DATED 4/26/11. NOR WERE INTERVENTIONS PROVIDED TO THE CARE PROVIDERS DESCRIBING METHODS TO REDUCE THE RISK FOR FALLING AS A RESULT OF POSTURAL [MEDICAL CONDITION], SUCH AS DANGLING AT THE BEDSIDE, ASSISTING THE RESIDENT TO STAND UPON RISING, ETC. A REVIEW OF RESIDENT #1'S COMPUTER GENERATED BLOOD PRESSURE READINGS SHOWED THAT BETWEEN 4/26/11 AND 5/2/11, HIS SYSTOLIC BLOOD PRESSURE RANGED BETWEEN 100-128 MILLIMETERS OF MERCURY (MMHG) AND HIS DIASTOLIC BLOOD PRESSURE RANGED BETWEEN 60-84MMHG, WITH THE EXCEPTION OF THREE OCCASIONS (4/28/11, 4/29/11 AND 5/1/11) WHEN HIS BLOOD PRESSURE WAS LOW AT 92/60MMHG, 88/42MMHG, AND 96/52MMHG RESPECTIVELY. NONE OF THE READINGS SAY WHETHER THE RESIDENT WAS IN A SITTING, STANDING, OR LYING POSITION WHEN THE BLOOD PRESSURES WERE TAKEN. DURING THE INVESTIGATION ON 6/6/11 AT 12:30 P.M. EASTERN DAY LIGHT TIME (EDT), LICENSED PRACTICAL NURSE (LPN) STAFF 'B' WAS OBSERVED TAKING RESIDENT #1'S BLOOD PRESSURE AS HE WAS SEATED IN HIS WHEELCHAIR. TWO READINGS ON HIS LEFT ARM WERE 98/46MMHG AND 96/48MMHG; ONE READING ON HIS RIGHT ARM WAS 92/41MMHG. WHEN ASKED WHEN SHE WOULD REPORT AN ABNORMAL BLOOD PRESSURE READING TO THE PHYSICIAN, SHE STATED, "SOMETIMES THERE ARE DOCTOR'S ORDERS WITH PARAMETERS, BUT I DON'T BELIEVE SO FOR THIS RESIDENT. I WOULD REPORT ANYTHING BELOW 100MMHG SYSTOLIC OR 50MMHG DIASTOLIC." RESIDENT #1'S BLOOD PRESSURE READING ON 5/1/11 (96/52) WAS ENTERED INTO THE COMPUTER AT 1:08 P.M. THE NURSING NOTES REVEALED THAT LATER THAT DAY AT 3:00 P.M., "A VISITOR SAID SHE SAW RESIDENT (#1) TRY TO STAND FROM THE WHEELCHAIR AND RESIDENT'S KNEES BUCKLED AND RESIDENT SLID TO FLOOR." FURTHER REVIEW OF THE RESIDENT RECORD REVEALS THAT ON 5/2/11, AFTER RESIDENT COMPLAINED OF RIGHT HIP AND GROIN PAIN, HE WAS TRANSFERRED TO THE emergency room AND admitted to the hospital with [REDACTED]. THE HOSPITAL'S ATTENDING PHYSICIAN WROTE IN HIS HISTORY AND PHYSICAL, DATED 5/2/11, "THE PATIENT SUSTAINED A FRACTURE status [REDACTED]. THE 5/7/11 DISCHARGE SUMMARY FROM THE HOSPITAL READS IN PART, "[MEDICAL CONDITION] DURING THIS ADMISSION ATTRIBUTED TO DEHYDRATION RESPONDED WELL WITH IV FLUID." THE HOSPITAL DISCHARGE SUMMARY ALSO SHOWED RESIDENT'S #1'S BLOOD PRESSURE MEDICATIONS WERE LOWERED WITH [MEDICATION NAME] CUT TO HALF THE DOSE, AND A LOW DOSE OF [MEDICATION NAME] STARTED. THE DIURETIC MEDICATION [MEDICATION NAME] WAS DISCONTINUED AND A LOW DOSE OF [MEDICATION NAME] STARTED. A FURTHER REVIEW OF RESIDENT #1'S CARE PLANS SHOWED THAT ALTHOUGH THE FALL CARE PLAN WAS UPDATED ON 5/9/11, IT STILL DID NOT IDENTIFY THE NEED FOR MONITORING OR SPECIFIC INTERVENTIONS FOR THE POTENTIAL SIDE EFFECTS OF ANTIHYPERTENSIVE MEDICATIONS. ADDITIONALLY, THE RECORD FOR RESIDENT #1 SHOWED HE HAD A SECOND FALL. ACCORDING TO THE INCIDENT CHARTING (ENTERED ON 5/23/11 AT 8:36 P.M.), RESIDENT #1 WAS FOUND "SITTING ON THE FLOOR IN HIS ROOM BETWEEN THE BEDS, CHAIR WAS IN THE DOORWAY" ON 5/23/11 AT 2:12 P.M.. THIS CHARTING ALSO READS, "(IMMEDIATELY AFTER) BLOOD PRESSURE 104/52." ACCORDING TO THE FACILITY ACCIDENT/INCIDENT REPORT DATED 5/24/11, THERE WAS NO APPARENT INJURY. ( ) --